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CDC Acute Flaccid Myelitis (AFM) Patient Summary Form

CDC uses this form to classify suspected acute flaccid myelitis (AFM) cases against the national case definition. A neurologist, infectious disease physician or other treating clinician meets it when a patient develops acute flaccid limb weakness and the case is reported to the health department. It records onset, limb tone, preceding illness, MRI and CSF findings, and a 60-day outcome.

Who completes it

The treating clinician, often with health department staff, completes the clinical pages and the 60-day follow-up. The top block naming the person completing the form, a physician contact and the hospital is for local use only and is detached before the rest goes to CDC.

Submitting and payment

How to submit it
Give the form to the state or local health department, which sends the lower portion to CDC with the MRI report, MRI images and neurology consult note. At the 60-day follow-up, further records such as the discharge summary, EMG report and vaccine registry record follow for confirmed and probable cases.
Who pays
CDC lists no fee or payment for completing the form.

Good to know

  • The form asks about respiratory or gastrointestinal illness, measured fever of at least 38.0°C, and neck or back pain in the 4 weeks before limb weakness began.
  • Record polio vaccine doses (IPV, OPV or unknown type) documented before onset, and any travel outside the US in the 30 days before weakness.
  • The printed case definition notes that a normal spinal MRI in the first 72 hours after weakness onset does not rule out AFM.
  • CSF results from up to two lumbar punctures are entered, each with WBC, differential, RBC, glucose and protein. The current form is version 7.2, dated September 1, 2022.

Get the official form

Download the current version from the source each time; forms change without notice.

Acute Flaccid Myelitis: Patient Summary Form

Official pagePDF

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Frequently asked questions

What should be sent to CDC with the AFM patient summary form?

The MRI report, the MRI images and the neurology consult note go with the form. At the 60-day follow-up, confirmed and probable cases also need the discharge summary, history and physical, neurology and infectious disease consult notes, any EMG report, the vaccine registry record and diagnostic laboratory reports.

When is the AFM 60-day follow-up completed?

Page 3 is completed for every reported person under investigation 60 days after onset of limb weakness. It grades impairment from none through severe or death, and scores physical condition, upper and lower limb function, communication and vision, bladder and bowel control, and support needs.

How does CDC classify an AFM case?

The form prints the case definition: acute flaccid limb weakness without a clear alternative diagnosis, plus MRI evidence of a spinal cord lesion involving gray matter. Predominant gray matter involvement spanning one or more segments supports a confirmed case, undetermined predominance a probable case, and some gray matter involvement a suspect case.