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Get Arizona Anthrax Case Report Patient Information Name: Date Of Birth: Gender: Male Female Unknown

Ethnicity: Black Hispanic Pregnant Asian/Pacific Islander Not Hispanic Native American Other Unknown Due date: Underlying conditions/ Immunodeficiency: Worksites, schools, daycare center: Occupation: Employer: SOURCE OF REPORT Laboratory Physician Infection Control Practitioner Other: 1 Hospital Other Unknown PHYSICIAN Name: Hospital: Address: Telephone: Email: ILLNESS Onset date: Diagnosis date: Attending physician: Telephone: Hospital: Telephone: Date of discharg.

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