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    Acute Hemorrhagic Fever Syndrome - Ver Oct 12 2012 PDF

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    CHICKY
    This document appears to be a case report form for acute hemorrhagic fever syndrome surveillance in the Philippines. It collects identifying and clinical information on patients, including name, age, sex, address, date of admission, onset of illness, laboratory test results, and outcome. Laboratory confirmation is recommended if available. The case definition includes any hospitalized person with acute fever of less than 3 weeks and at least two hemorrhagic symptoms, excluding dengue fever cases.

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    Acute Hemorrhagic Fever Syndrome - Ver Oct 12 2012 PDF

    Uploaded by

    CHICKY
    53 views2 pages
    This document appears to be a case report form for acute hemorrhagic fever syndrome surveillance in the Philippines. It collects identifying and clinical information on patients, including name, age, sex, address, date of admission, onset of illness, laboratory test results, and outcome. Laboratory confirmation is recommended if available. The case definition includes any hospitalized person with acute fever of less than 3 weeks and at least two hemorrhagic symptoms, excluding dengue fever cases.

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    Acute Hemorrhagic Fever Syndrome_ver Oct 12 2012.pdf

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    This document appears to be a case report form for acute hemorrhagic fever syndrome surveillance in the Philippines. It collects identifying and clinical information on patients, including name, age, sex, address, date of admission, onset of illness, laboratory test results, and outcome. Laboratory confirmation is recommended if available. The case definition includes any hospitalized person with acute fever of less than 3 weeks and at least two hemorrhagic symptoms, excluding dengue fever cases.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    53 views2 pages

    Acute Hemorrhagic Fever Syndrome - Ver Oct 12 2012 PDF

    Uploaded by

    CHICKY
    This document appears to be a case report form for acute hemorrhagic fever syndrome surveillance in the Philippines. It collects identifying and clinical information on patients, including name, age, sex, address, date of admission, onset of illness, laboratory test results, and outcome. Laboratory confirmation is recommended if available. The case definition includes any hospitalized person with acute fever of less than 3 weeks and at least two hemorrhagic symptoms, excluding dengue fever cases.

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    Philippine Integrated Disease Case Report Form

    Surveillance and Response Acute Hemorrhagic Fever Syndrome

    Region: ____________________________ Province: ___________________________ Municipality/City: ________________________________________


    Name of DRU: _________________________________________________________________ Type: ⃞RHU ⃞CHO ⃞Gov’t Hospital ⃞Private Hospital ⃞Clinic
    Address: ______________________________________________________ ⃞Private Laboratory ⃞Public Laboratory ⃞Seaport/Airport

    Date Admit- Blood


    Patient Date of Admit- Date onset PCR Re- Out-
    Patient’s Full Name Age Sex Complete Address ted?
    ted/seen/ Culture
    No. Birth of illness sult come
    consulted Result

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___


    P - Positive
    Age: Indicate P - Positive A - Alive
    (specify
    D - days (specify organ- D - Died
    Response organism)
    Indicate First name, Middle name, M - months Specify Street/Purok/Subdivision, House #, Y - Yes ism) (specify
    Codes / mm/dd/yy mm/dd/yy mm/dd/yy N - Negative
    Last name Yr. - years Barangay, Municipality/City, Province N- No N - Negative date)
    Instructions ND - Not
    Sex:F - Female ND - Not done U - Un-
    done
    M - Male U - Unknown known
    U - Unknown

    Case Definition:
     Any hospitalized person with acute onset of fever of less than 3 weeks duration Note: Laboratory confirmation should be done if available
    and with any two of the following: hemorrhagic or purpuric rash, epistaxis, hema-
    temesis, hemoptysis, blood in stools, or other hemorrhagic symptom and the diag- Case classification: Not applicable
    nosis is not Dengue
    Philippine Integrated Disease Case Report Form
    Surveillance and Response Acute Hemorrhagic Fever Syndrome

    Date Admit- Blood


    Patient Date of Admit- Date onset PCR Re- Out-
    Patient’s Full Name Age Sex Complete Address ted?
    ted/seen/ Culture
    No. Birth of illness sult come
    consulted Result

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___

    ___/___/___ ___/___/___ ___/___/___


    P - Positive
    Age: Indicate P - Positive A - Alive
    (specify
    D - days (specify organ- D - Died
    Response organism)
    Indicate First name, Middle name, M - months Specify Street/Purok/Subdivision, House #, Y - Yes ism) (specify
    Codes / mm/dd/yy mm/dd/yy mm/dd/yy N - Negative
    Last name Yr. - years Barangay, Municipality/City, Province N- No N - Negative date)
    Instructions ND - Not
    Sex:F - Female ND - Not done U - Un-
    done
    M - Male U - Unknown known
    U - Unknown

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