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Confidential Morbidity Report (CMR) for Alzheimer's Mobile App

The Center for Infectious Diseases, Division of Communicable Disease Control, requires the information within this app and is intended for use by health professionals only. Reportable Diseases and Conditions for specific diseases and conditions are mandated by state laws and regulations to be reported by healthcare providers and laboratories to local health officers. The Confidential Morbidity Report (CMR) for Alzheimer's mobile app provides an easy to complete paperless version of the mandated case report form specific to Alzheimer's. The app is filled out using a smartphone or tablet. This GoCanvas app can be made HIPAA compliant and is ideal for Disease Surveillance and Reporting.

The Center for Disease Control, national centers, children’s hospital, public health and local health departments urge health care providers to promptly report infectious diseases as well as virus infections. It is important for patient safety. Pregnant women, immigrant children, illegal immigrants and travelers are at a greater risk for communicable diseases and birth defects from lack of infection control and virus transmission. This app is specific to Alzheimer's but please don’t hesitate to report any suspicious respiratory illness, flu, rash, pneumonia or virus infection. Timely reporting can stop outbreaks.

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Take a peek inside the Confidential Morbidity Report (CMR) for Alzheimer's Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico dropdown

    DISEASE BEING REPORTED

  • Ico textbox

    Patient Name - Last Name

  • Ico textbox

    First Name

  • Ico textbox

    MI

  • Ico textbox

    Home Address: Number, Street

  • Ico textbox

    Apt.

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico integer

    ZIP Code

  • Ico textbox

    Home Telephone Number

  • Ico textbox

    Cell Telephone Number

  • Ico textbox

    Work Telephone Number

  • Ico textbox

    Email Address

  • Ico dropdown

    Primary Language

  • Ico textbox

    Other:

  • Ico date

    Birth Date

  • Ico integer

    Age

  • Ico checkbox

    Years

  • Ico checkbox

    Months

  • Ico checkbox

    Days

  • Ico dropdown

    Gender

  • Ico textbox

    Other:

  • Ico dropdown

    Pregnant?

  • Ico date

    Est.

  • Ico textbox

    Country of Birth

  • Ico textbox

    Occupation or Job Title

  • Ico dropdown

    Occupational or Exposure Setting (check all that apply):

  • Ico textbox

    Other (specify):

  • ...and More!

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