Nevada Confidential Morbidity Form Submission Results

Results Page


Facility Name:
Patient's Country of Birth:
Patient's Zip Code:
Disease/Condition:
Patient's Race:
Patient's Residing County:
Patient's Birth Year:
Patient's First Name:
Patient's Last Name:
Provider's First Name:
Provider's Last Name:
IDProvider_First_NameProvider_Last_NameProvider_InitialProvider_AreacodeProvider_PhoneProvider_FaxReporter_First_NameReporter_Last_NameReporter_InitialReporter_TitleFacility_NameFacility_AreacodeFacility_PhoneReport_DatePatient_First_NamePatient_Last_NamePatient_InitialPatient_GenderPatient_TransgenderPatient_RacePatient_EthnicityPatient_Marital_StatusPatient_PregnantPatient_EDCPatient_IncarceratedPatient_DOBPatient_CountryPatient_Arrival_DatePatient_LanguagePatient_GuardianPatient_AreacodePatient_PhonePatient_Street_AddressPatient_CityPatient_StatePatient_ZipPatient_CountyPatient_OccupationPatient_SSNPatient_NumberComments__________________________________________________Disease/Condition_NameAdmission_DateOnset_DateDiagnosis_DateDischarge_DateDeceased?Disease_DODLab?Lab_ResultTreated?Symptom___________________________________________________
5Cat Johnson J702987-0987987-0325GraceColeKNurseSunrise Hospital702635-96873/3/2008WayneLeeOMaleYes, Female to MaleAsianNon-HispanicSeperatedNoMM/DD/YYYYYes02/02/1990CanadaMM/DD/YYYYEnglish 702659-9632555 Cottage CircleLas VegasNV89119ClarkStudent5239652146532365614 441A.490 Chlamydia trachomatis infection03/03/0802/22/0803/03/0803/03/08NoMM/DD/YYYYNo YesPatient received a course of antibiotic
6KennyOrtegaH702674-0978674-0532    Kenny Ortega Hematologist Clinic702333-98523/12/2009KellyGarnettJFemaleNoBlackNon-HispanicMarriedYes09/26/2009No05/05/1977United StatesMM/DD/YYYYEnglish 702653-32144193 Arrowhead Ave.Las VegasNV89119ClarkMarketing Executive5302635215643515464 441A.595 Lyme disease03/01/200902/28/200903/10/200903/01/2009NoMM/DD/YYYYYesQuestYesRed bulllseye mark was seen on her right leg. Patient was given a course of Antibiotic. She will return for another course if necessary.
7NikkiSanchezJ702989-0909989-0908MaxineIbarraJAdministrative AssistantSanchez Family Pratice702965-986505/02/2002AngelMartinezKMaleNoOtherHispanicWidowedNoMM/DD/YYYYYes05/05/1965Spain04/22/1980Spanish 702524-55559087 Traveling Acrobat Dr.Las VegasNV89119ClarkMechanic56329658213646468 441A.650 Q fever04/01/200202/01/200204/15/200204/01/2002NoMM/DD/YYYYYesQuestYesGiven a course of Antibiotics. Patient is convalescing well
1JohnDoeR702555-5555555-5623JaneDoeINurseSunset Hospital702563-96851/1/2009KellyGarlandPFemaleNoBlackNon-HispanicSingleNoMM/DD/YYYYNo02/02/1933United StatesMM/DD/YYEnglish 702774-98568542 Windows AveHendersonNV89123ClarkRetired5749635214554652656 441A.595 Lyme disease04/04/200804/03/200804/06/200804/04/2008NoMM/DD/YYYYYesSteinberg DiagnosticYesFatigue, fever
2KennyGomezP702698-8524698-8354PerryKellerKNurseSt.Rose Hospital702412-02029/8/2008JackSparrowLMaleNoWhiteNon-HispanicWidowedNoMM/DD/YYYYNo02/03/1978Canada01/01/1990English 702767-09872343 Wine RiverLas VegasNV89109ClarkChef5216935212547892112Patient is home resting. 441A.615 Meningitis09/07/200809/06/200809/08/200809/10/2008NoMM/DD/YYYYYesQuestYesPatient was in shock. Patient condition now stable
3MacolmJonesO702278-0987278-0022    Sunrise Hospital702874-99991/1/2009MildredDiazKFemaleNoOtherHispanicSingleNoMM/DD/YYYYNo09/05/1990Mexico12/25/1996SpanishBenny Diaz702541-96527806 Cottage HillLas VegasNV89109ClarkStudent5742315682251211133Patient seems to be recovering well441A.535 Giardiasis01/01/200901/01/200901/01/200901/03/2009NoMM/DD/YYYYNo YesStomach Cramps, Vomitting
4KennyCole 702564-0987564-0333    Nevada Clinics702963-65218/1/2007KimLeeOMaleNoAsianNon-HispanicSingleNoMM/DD/YYYYNo05/05/1932Singapore09/02/1988Chinese 702542-93328890 Heather DriveLas VegasNV89123ClarkTruck Driver5896325142552436431 441A.570 Hepatitis: B; C; Delta; unspecified08/02/2007007/22/200708/02/200702/02/2007NoMM/DD/YYYYYesSteinberg DiagnosticsNoNo treatment until the result if Liver Biopsy is complete.
10CampSaltK70241523655463266    Sunrise Hospital702654545412/25/2001KimKayLFemaleNoWhiteNon-HispanicSingleNo No02/05/1992United States English 70234545547678 Maple LaneLas VegasNV89108ClarkStudent6266562656565656565No treament needed at this time441A.450 AIDS;HIV12/24/200112/01/200112/24/200112/25/2001No YesQuestNoFever, fatigue
11AndresGuillermoK70295565629553025    Andres Family Practice702555989803/06/2005JakeCampLMaleYes, Female to MaleNative AmericanNon-HispanicSingleNo No11/11/1981italy11/12/1986English 7025698512654 Hurricane Rd.RenoNV89452WashoeTV Anchor6541658468648184864user died due to overwhelming infections441A.520 Encephalitis03/03/200503/01/200503/01/2005 Yes03/06/2005YessteinbergYesHigh fever, disorientation, vomiting
12JasonKingK77565165265649465    Carson City hospital775354534506/01/2006AvonMayKFemaleNoBlackNon-HispanicMarriedNo No12/22/1977    7756546541980 Hudson drivecarson CityNV85525carson citycameraman3545435445468464848T-cell count very low. started patient on HAART441A.450 AIDS;HIV05/26/200604/01/200605/28/200606/01/2006No Yescarson city hospitalYesfever, chills, fatigue
13JasonKingK77556465465844184    carson City Hospital775534545604/04/2004LaceyJackson FemaleNoWhiteNon-HispanicSingleNo No05/26/1966France05/11/1977French 77553454549840 Traveling AcrobatCarson cityNV82636carson CityComedian3545645344684848448 441A.515 E. coli 0157:H704/02/200404/02/200404/03/200404/04/2004No Yescarson City hospitalNofever Diarrhea, vomiting
14DarrenHayesJ77565656465451515    Reno Medical center775316516503/09/2007RichardColtKMaleNoWhiteNon-HispanicSingleNo No03/26/1977Australia03/22/1981English 7755465146989 Bowler Hat laneRenoNV89233WashoePharmacists1651651656514654545Patient is being treated with Antibiotics441A.595 Lyme disease03/09/200702/26/200703/09/200703/09/2007No Yesreno medical centerYesClassic Red Rulls eye rash
15KeeferCruzJ77554564568748448    Ely Hospital775354534502/05/1999NickCaperLMaleNoOtherHispanicSingleNo No02/05/1952    7755664654789 Blue Bell CirElyNV86656White PineMiner2652665461547684684 441A.557 Hantavirus infection02/02/199902/01/199902/02/199902/05/1999No No Nofever, vomiting, cough
16JimmyKimmel 7755315645     Reno Medical center775454444403/31/2002NicoleLivelyLFemaleNoPacific IslanderNon-HispanicSingleNo No06/03/1979    77584894897798 Hunter StreetRenoNV86654Washoe 6546546466864867687 441A.490 Chlamydia trachomatis infection03/31/200203/22/200203/31/200203/31/2002No NoReno medical CenterYesdischarge, pain
17DarrenHayes 77565655655445487MildredIvesLNurseVirginia City Center775354564609/26/2001PollyBuckmanOFemaleNoBlackNon-HispanicMarriedNo No06/22/1965    77554584849880 Casey streetVirginia cityNV86565StoreyProfessor5454644486161468464 441A.665 Rocky Mountain spotted fever09/22/200109/14/200109/25/2001 No NoVirginia city centerYesHigh fever