Alpha-gal Syndrome Case Report Form

Use for Alpha-gal syndrome (AGS) case reporting. Visit https://ndc.services.cdc.gov/ for complete case definition. 

CDC#

Patient Name: 

Address:

City:

Date submitted (mm/dd/yyyy):

Healthcare provider's name:

Local Patient ID. (if reported): 

Local ID Site State

1. State of residence (postal abbrev.): 2. County of residence: 3. Sex:

Male Female Unknown

4. Patient age (years) 

at time of case 

investigation:

5. Race (check all that apply):

White 

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Other race

Unknown

Refused

6. Hispanic or 

Latino ethnicity:

Yes

No

Unknown

CLINICAL CHARACTERISTICS AND OUTCOMES OF AGS

Enter as much information that is known, with the year (YYYY) at a minimum. For an unknown day or month, that value may be entered 

as '99'. If no date available, leave blank.

7a. Date of most recent AGS reaction 

that prompted this report (mm/dd/yyyy):

7b. Has the patient had prior AGS reactions?

Yes No Unknown

7c. Date of first AGS 

reaction (mm/dd/yyyy):

7d. Date of first AGS diagnosis by a 

healthcare provider(mm/dd/yyyy):

8. Has the patient ever experienced any of the 

following signs or symptoms of AGS during 

a reaction? (Check all that apply)

Abdominal pain

Nausea

Diarrhea

Vomiting

Heartburn/indigestion

Hives

Itching

Swelling of lips, tongue, throat, face, 

eyelids, or other associated structures

Shortness of breath

Cough

Wheezing

Acute episode of hypotension

Other (specify): 

9. Has the patient ever experienced signs or 

symptoms of an AGS reaction within 2–10 

hours after consumption of any of the following? 

(Check all that apply)

Beef

Pork

Lamb/mutton

Goat

Game meat (such as venison, boar, bison, 

elk, rabbit)

Milk or milk products (such as cow’s milk, 

cheese, yogurt, butter, ice-cream)

Gelatin/glycerin-containing food products 

(such as gelatin dessert, pudding, gummy 

candy, marshmallows)

Gel-cap medications

‘Red meat’, not specified

Other food product or additive (specify): 

10. Has the patient ever experienced signs or 

symptoms of an AGS reaction within two 

hours after receiving any of the following 

pharmaceutical or medical products 

intramuscularly, intravenously, 

or subcutaneously?

Vaccines (specify): 

Monoclonal antibodies (specify): 

Anti-venom

Heparin

Other (specify): 

11. Has the patient ever experienced 

anaphylaxis due to an AGS reaction

(involvement of two or more organ systems; 

including symptoms such as severe 

difficulty breathing, swelling of tongue 

or throat, drop in blood pressure or shock 

as diagnosed by a medical provider)?

Yes

No

Unknown

12. Was the patient ever hospitalized because 

of an AGS reaction?

Yes

No

Unknown

If yes, please provide month and year(s): 

13. Did the patient die because of 

an AGS reaction? 

Yes

No

Unknown

If yes, date (mm/dd/yyyy): 

CS328065-A 2/3/2023
TICK BITE HISTORY PRIOR TO AGS ONSET OR DIAGNOSIS

14. In the 12 months before an AGS reaction or diagnosis (use earlier date), did the patient notice any tick bites? 

Yes No Unknown

15. Alpha-gal specific Immunoglobulin-E (alpha-gal sIgE) and total IgE testing

Date of 

specimen 

collection

(mm/dd/yyyy)

Testing laboratory

Alpha-gal sIgE 

quantitative 

 value

Alpha-gal sIgE result Total IgE 

quantitative value

Reactive Nonreactive Unknown Not performed

Reactive Nonreactive Unknown Not performed

Reactive Nonreactive Unknown Not performed

Reactive Nonreactive Unknown Not performed

Reactive Nonreactive Unknown Not performed

16a. Skin prick testing for alpha-gal component reactivity:

Reactive

Nonreactive

Unknown

Not performed

16b. Date of test (mm/dd/yyyy):

If additional testing performed, please specify in comments.

17. Case classification:

Confirmed Probable Suspect Not a case Unknown

State Health Department Official who reviewed this report:

Name:

Title:

Date:

Phone number:

Email address:

Comments:

LABORATORY