Infectious Disease Pathology Assessment Form
Use this form to capture the essential clinical, specimen, and pathology findings needed for an infectious disease pathology assessment.
Patient and Specimen Details
Patient Identifier
*
Age Group / Age
*
Please Select
Neonate
Infant
Child
Adolescent
Adult
Older adult
Exact age unknown
Sex / Gender
Female
Male
Intersex
Prefer to self-describe
Prefer not to say
Specimen Type
*
Please Select
Biopsy
Resection specimen
Swab
Blood
Sputum
Urine
Stool
Tissue aspirate
CSF
Other
Specimen Source / Site
*
Date of Specimen Collection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submitting Clinician / Service
*
Infectious Disease Pathology Assessment
Likely Infectious Etiology / Suspected Organism Group
*
Please Select
Bacterial
Viral
Fungal
Parasitic
Mycobacterial
Mixed/Polymicrobial
Unknown
Other
Key Histopathology Findings
*
Severity / Extent of Pathologic Involvement
*
Minimal
1
2
3
4
5
6
7
8
9
Extensive
10
1 is Minimal, 10 is Extensive
Inflammation and Other Relevant Findings
*
Rows
Absent
Mild
Moderate
Marked
Acute inflammation
1
2
3
4
Chronic inflammation
5
6
7
8
Necrosis
9
10
11
12
Granulomas
13
14
15
16
Abscess formation
17
18
19
20
Tissue invasion by organisms
21
22
23
24
Vascular invasion
25
26
27
28
Red-flag: concern for rapid progression
29
30
31
32
Final Impression / Provisional Diagnosis
*
Clinical Context and Follow-up
Presenting Symptoms or Syndrome
Clinical Context and Follow-up
Known exposure
Relevant risk factors
Current antimicrobial treatment
Recommend follow-up action
Submit
Should be Empty: