Patient First Name *First Name is required. Middle Name Last Name *Last Name is required. Race * White Black/African American Asian American Indian Pacific Islander Other At least 1 Race checkbox must be selected. Other Race Ethnicity * Hispanic Non-Hispanic Ethnicity is required. Sex * Male Female Sex is required. Date of BirthDate of Birth must be between 11/26/1904 and 11/25/2024.Please enter a valid date in M/d/yyyy format AgeAge must be between 0 and 120. Address Line 1 *Address Line 1 is required. Address Line 2 City *City is required. Postal Code *Postal Code is required.Please enter a valid Postal Code. Phone Number *Phone Number is required.Please enter a valid Phone Number. Occupation Parent/Guardian Mother's Name Mother's Home PhonePlease enter a valid Mother's Home Phone. Mother's Work PhonePlease enter a valid Mother's Work Phone. Mother's Cell PhonePlease enter a valid Mother's Cell Phone. Father's Name Father's Home PhonePlease enter a valid Father's Home Phone. Father's Work PhonePlease enter a valid Father's Work Phone. Father's Cell PhonePlease enter a valid Father's Cell Phone. Disease Disease Name * Acquired Immune Deficiency Syndrome (AIDS) Acute flaccid myelitis Anthrax Arbroviral disease - West Nile, WEE, & SLE - indicate virus if possible in comments Babesiosis Blood lead Botulism Brucellosis Campylobacter infections Chancroid Chikungunya virus Chlamydia trachomatis genital infection Cholera Coccidioidmycosis Coronavirus Disease 2019 (COVID-19) Cryptosporidiosis Cyclospora infection Diphtheria Ehrlichiosis Escherichia coli O157:H7 (and other shiga-toxin producing E. coli, also as STEC) Giardiasis Gonorrhea Haemophilus influenzae, invasive disease Hantavirus Pulmonary Syndrome Hemolytic uremic syndrome, postdiarrheal Hepatitis A Hepatitis B Hepatitis B during pregnancy Hepatitis C Hepatitis, viral (acute and chronic) Histoplasmosis Human Immunodeficiency Virus (HIV) (includes Viral Load Tests) Legionellosis Leprosy (Hansen disease) Leptospirosis Listeriosis Lyme disease Malaria Measles (rubeola) Meningococcal Disease Mumps Other - Please state in comments Perinatal Hepatitis C Pertussis (whooping cough) Plague (Yersinia pestis) Poliovirus Psittacosis Q Fever Rabies, human and animal Rubella, including congenital rubella syndrome Salmonellosis, including typhoid fever Severe Acute Respiratory Syndrome (SARS) Shigellosis Smallpox Spongioform encephalopathy (STE) or prion disease (includes vCJD) Spotted fever rickettsiosis Streptococcal invasive, drug resistant form from Group A or pneumoniae Syphilis, including congenital syphilis Tetanus Toxic shock syndrome, streptococcal and staphylococcal Trichinosis Tuberculosis, active disease Tuberculosis, latent infection Tularemia Vaccinia, post vaccination infection or secondary transmission Varicella (chickenpox) Vibriosis (Vibrio species) Viral hemorrhagic fever West Nile Fever Yellow fever Disease Name is required. Symptoms Onset DateOnset Date must be between 11/26/2019 and 11/26/2024.Please enter a valid date in M/d/yyyy format Diagnosis DateDiagnosis Date must be between 11/26/2019 and 11/26/2024.Please enter a valid date in M/d/yyyy format Treatment Description Date Treatment PrescribedDate Treatment Prescribed must be between 11/26/2019 and 11/26/2024.Please enter a valid date in M/d/yyyy format Hospitalized? Yes No Unknown If Yes, where? Disease Specific Immunizations and Rash Information Immunizations and Dates If rash present, rash onset dateIf rash present, rash onset date must be between 11/26/2019 and 11/26/2024.Please enter a valid date in M/d/yyyy format Varicella Rash Onset Description Severity of Rash Unknown Mild (<50 lesions) Moderate (50-500) Severe (>500) Laboratory Testing Was laboratory testing ordered? Yes No Unknown Laboratory Specimen DateSpecimen Date must be between 11/26/2019 and 11/26/2024.Please enter a valid date in M/d/yyyy format Tests Requested Doctor/Clinic Doctor Name Clinic Name Doctor PhonePlease enter a valid Doctor Phone. Additional Information If yes to any of the following, please provide details (e.g., estimated delivery date, child care facility name and address, travel history) in the Comments field. Pregnant? Yes No Unknown School Association? Yes No Unknown Child Care Association? Yes No Unknown Adult Care Home Resident? Yes No Unknown Lives in Other Group Home? Yes No Unknown Food Handler? Yes No Unknown History of Travel? Yes No Unknown Comments School School or other reporting facility School District Cheney Clearwater Derby Goddard Haysville Maize Mulvane Renwick Valley Center Wichita Name of Person Making Report *Please enter your name in the Name of Person Making the Report field. Reporting Phone Number *Please enter your phone number in the Reporting Phone Number field.Please enter a valid Reporting Phone Number. School Nurse (if different from person making this report) School Nurse PhonePlease enter a valid School Nurse Phone. Grade Teacher Name Last Attendance DateLast Attendance Date must be between 11/26/2022 and 11/26/2024.Please enter a valid date in M/d/yyyy format