North Dakota Morbidity Report

North Dakota Department of Health
Division of Disease Control
Confidentiality Protected by North Dakota Century Codes 23-07-02.1 and 23-07-02.2

*North Dakota Department of Health will follow up on incomplete reports as needed.

Patient Information

Last Name   First Name   Gender  
Street Address
City   State   Zip Code County
Telephone No.
Date of Birth     Race Ethnicity
Name of Employer Business Telephone Marital Status

Clinical Information

Disease or Condition   Date of Onset  
Was Patient Hospitalized? Is Case Pregnant?   Outcome
Date Admitted   Date Discharged  
Name of Hospital Health Care Provider
Was Person Treated? Treatment Date  

Lab Information

Other Information

Person Reporting Address/Facility 
Telephone Number 
Cancer SiteDate Cancer DiagnosedCancer Histology