Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

INITIAL CLINICAL HISTORYPlease use the following key, 1=Y, 2=N, 9=U, where applicable.Questions Answer Questions AnswerWas baby normal at birth?Spasms or convulsions?Normal cry and suck during first 2 days?Complications?Stopped sucking after 2 days?Did the baby die?Arched back? Age at death: DaysStiffness? Age of onset in days: Days ( 99=Unknown)Onset of symptoms: ____/_____/______TREATMENTDate of admission: ______/_______/______ Questions Answer 1=Y, 2=N, 9=UMedical record number: __________Seen in OPD?Facility Address:Admitted?COMMENTS:RESPONSEPlease use the following key, 1=Y, 2=N, 9=U, where applicable.QuestionsMother given protective dose ofTT within 3 months of report?Supplemental immunization withinsame locality as the case?AnswerDate of response: ______/______/_____Details of response: _________________________________________________FINAL CLASSIFICATION OF THE CASE: Neonatal Tetanus: 1=Yes, 2=No, 9=UnknownINVESTIGATORName: _____________________________________ Title: _________________________________________Unit: _________________Address: ___________________________________ Phone: ___________________182Technical Guidelines for Integrated Disease Surveillance and Response in Ghana