Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

Annex 22Case Investigation Form – Acute Flaccid ParalysisOfficial Use Epid Number: _______-_______-_______-______Only (completed by district team) Region District Year Onset Case NumberReceived : _______/_______/_______IDENTIFICATIONDistrict: ____________________________ Region: _____________________________Nearest health Village/ Town/facility to village: ___________________ Suburb: ____________________ City: ____________________Address: ____________________________________________________________________________________________________________________________________________________________________Name of patient: _______________________________ Mother/Father: ______________________________Sex: 1 = Male, 2 = Female Date of birth: _____/_____/_____ or Age: years _____ months _____(If DOB is unknown)NOTIFICATION/INVESTIGATIONNotified by: ____________________ Date Notified: ____/____/____ Date Investigated: ____/____/____HOSPITALIZATIONAdmitted to hospital? 1= Y, 2= NoFacility address:Date of admission: ____/____/____ Medical record number: __________CLINICAL HISTORYPlease use the following key, 1=Yes, 2=No, 9=Unknown.QuestionAnswerFever at onset of paralysis Site of paralysisParalysis progresses 4, last dose ____/____/____Annex 22: Case Investigation Form - Acute Flaccid Paralysis183