Allegheny County Health Department

542 4th Avenue, Pittsburgh, PA 15219 Phone: 412-687-ACHD (2243) Fax: 412-578-8325

CO Poisoning Report



Patient Details

Last Name: First Name: DOB: Gender:

Race: Date of Exposure: Source of Exposure:

Address

Street: Address2: City: State: Zip: Phone:

Symptoms (Check all that apply)


Other Symptoms:

Carboxyhemoglobin level (cases include those 5% or higher with symptoms or 15% with or without symptoms)

Reporting Details

Reporting Institution: Reporting Clinician: Reporter's Phone: Date of Report: