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

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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