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Zika Virus Disease Request for Testing

  1. Physician Use Only
  2. Reason for Testing
  3. Travel History
  4. Did Patient Live in a Dengue-Endemic Country:
  5. Reporting Jurisdiction
  6. Demographic Information
  7. Obstetric Information (if applicable)
  8. Pregnant:
  9. Was Fetal Ultrasound done?
  10. Finding of ultrasound:
  11. Vaccination Information
  12. Received Yellow Fever Vaccine:
  13. Received Japanese Encephalitis Vaccine:
  14. Clinical Information (if applicable)
  15. Fever:
  16. Rash:
  17. Type:
  18. Additional Clinical Symptoms:
  19. Specimen Information
  20. Specimen Type:
  21. Leave This Blank:

  22. This field is not part of the form submission.