Today M-D-Y
Facility Name:
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Facility Type:
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County Health Department Hospital Emergency Department Urgent Care Other outpatient clinic
Facility Address:
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Facility City:
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Facility State:
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Illinois Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Facility Zipcode:
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Requesting Clinician Name:
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Clinician Direct Phone Number:
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XXX-XXX-XXXX | Please provide a cell phone or staffed office line. Do NOT provide a general clinic number only.
Clinician Email:
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Pharmacy contact name:
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Please provide a pharmacy contact who can receive medication delivery.
Pharmacy contact direct phone number:
* must provide value
Please do not provide a general number/line. Phone number will be used to coordinate medication delivery if needed.
Pharmacy contact email:
* must provide value
Administrative Contact Name:
* must provide value
Please list appropriate individual to communicate with regarding medication delivery and logisitics (e.g. Clinic Manager, Infection Preventionist, etc.)
Administrative Contact Phone Number:
* must provide value
Please do not provide a general number/line. Phone number will be used to coordinate medication delivery if needed. Please input in XXX-XXX-XXXX format.
Administrative Contact Email:
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Additional contact phone number:
First Name:
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Last Name:
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Date of Birth:
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M-D-Y
View equation integer required
Street Address:
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City:
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State:
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Illinois Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zipcode:
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Phone Number:
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XXX-XXX-XXXX
Sex at Birth:
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Male
Female
Unknown
Gender:
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Female
Male
Transgender/female-to-male (FTM)
Transgender/male-to-female (MTF)
Genderqueer/gender nonconforming
Other gender category
Unknown
Female
Male
Transgender/female-to-male (FTM)
Transgender/male-to-female (MTF)
Genderqueer/gender nonconforming
Other gender category
Unknown
Ethnicity:
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Hispanic
Non-Hispanic
Unknown
Hispanic
Non-Hispanic
Unknown
The option "
Race:
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Check all that apply.
Weight
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lbs
Is the patient currently an inpatient or an outpatient?
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Inpatient
Outpatient
For Vanderbilt-affiliated facilities only : Please indicate why this patient is not enrolled in the STOMP study:
Patient did not meet STOMP eligibility criteria
Patient declined STOMP enrollment
Patient did not meet STOMP eligibility criteria
Patient declined STOMP enrollment
This question only needs to be answered by facilities associated with Vanderbilt. All other health systems can leave this question blank.
Has the patient been tested for monkeypox?
* must provide value
Yes and positive Yes and pending No
Treatment indications: Select all that apply
Evidence of sepsis or other clinical evidence of viremia
Encephalitis
Confluent lesions
Lesions near or directly involving the eye
Hospitalized with monkeypox as reason for admission
Severe or difficult to control secondary bacterial infection
Proctitis (particularly with tenesmus, challenges in pain control, or rectal bleeding) or rectal lesions at risk for fistulization or scarring
Gastroenteritis with nausea/vomiting
Bronchopneumonia
Living with HIV and not virally suppressed or has active opportunistic infection
Hematologic malignancy
History of solid organ transplantation
Hematopoietic stem cell transplant < 24 months post-transplant or ≥ 24 months but with graft-versus-host disease or malignant disease relapse
Severe immunocompromise, including a condition actively requiring chemotherapy, radiation, or continuous or high-dose systemic corticosteroids
Autoimmune disease requiring immunosuppression or with immunodeficiency as a clinical component
Age < 8 years of age
Pregnant or breastfeeding
A disease which could increase risk of stricture or fistula such as inflammatory bowel disease
People with a condition affecting skin integrity - conditions such as atopic dermatitis, eczema, burns, impetigo, varicella zoster virus infection, herpes simplex virus infection, severe acne, severe diaper dermatitis with extensive areas of denuded skin, psoriasis, or Darier disease (keratosis follicularis)
Oral or throat lesions that interfere with adequate food/liquid intake due to pain or obstruction
Lesions near or directly involving the urethra with potential for obstruction, ulceration, or stricture
Evidence of sepsis or other clinical evidence of viremia
Encephalitis
Confluent lesions
Lesions near or directly involving the eye
Hospitalized with monkeypox as reason for admission
Severe or difficult to control secondary bacterial infection
Proctitis (particularly with tenesmus, challenges in pain control, or rectal bleeding) or rectal lesions at risk for fistulization or scarring
Gastroenteritis with nausea/vomiting
Bronchopneumonia
Living with HIV and not virally suppressed or has active opportunistic infection
Hematologic malignancy
History of solid organ transplantation
Hematopoietic stem cell transplant < 24 months post-transplant or ≥ 24 months but with graft-versus-host disease or malignant disease relapse
Severe immunocompromise, including a condition actively requiring chemotherapy, radiation, or continuous or high-dose systemic corticosteroids
Autoimmune disease requiring immunosuppression or with immunodeficiency as a clinical component
Age < 8 years of age
Pregnant or breastfeeding
A disease which could increase risk of stricture or fistula such as inflammatory bowel disease
People with a condition affecting skin integrity - conditions such as atopic dermatitis, eczema, burns, impetigo, varicella zoster virus infection, herpes simplex virus infection, severe acne, severe diaper dermatitis with extensive areas of denuded skin, psoriasis, or Darier disease (keratosis follicularis)
Oral or throat lesions that interfere with adequate food/liquid intake due to pain or obstruction
Lesions near or directly involving the urethra with potential for obstruction, ulceration, or stricture
Does the patient have any contradindications to oral medication?
* must provide value
Yes
No
Generate TPOXX Treatment Initiation email?
Yes
No
Yes
No
Will this patient initially receive PO or IV TPOXX?
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PO
IV
If this patient begins on PO and later switches to IV TPOXX with or without VIVIG, please update this record in the "TDH comments" section with that information.
Is this request from a facility with prepositioned medication?
Current facilities with prepositioned meds :
Vanderbilt
Regional One
Jackson-Madison Hospital
ETSU/Johnson City COE
NDR (Nashville Metro HD)
CHI Memorial/CHI Memorial North (Hixson)
St. Jude
St. Thomas - Rutherford
St. Thomas - Midtown
St. Thomas - West (will pull from Midtown stock per Calita)
Yes
No
Note: These facilities have pre-positioned medication and do not need medication transferred.
Which facility?
* must provide value
Vanderbilt Regional One Jackson Madison Hospital ETSU/Johnson City COE NDR (Nashville Metro HD) CHI Memorial/CHI Memorial North (Hixson) St. Jude St. Thomas - Rutherford St. Thomas - Midtown St. Thomas - West
Generate treatment initiation email for clinician at a facility with prepositioned medication?
Yes
No
Note: this will generate initiation email without transport information.
View equation How many bottles are to be transported?
Who approved?
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Is this a Health Department or a Private Provider?
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Health Department
Private Provider
Health Department
Private Provider
Informed Consent obtained?
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Yes
No
Informed Consent Document Upload
Send required documentation reminder email?
Yes
No
TDH Complex Case Follow-up Please select which therapies this patient is receiving.
Please list the "other" therapies here:
Please indicate dates each therapy started and ended (if known).
Pathology reports upload:
Is this patient deceased?
Yes
No
Please upload the death certificate.
Please include any additional relevant clinical information known.
