Form 4 Swine Influenza Case Investigation Form

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Transcript of Form 4 Swine Influenza Case Investigation Form

  • Form_4_April29,2009CaseinvestigationformforSwineInfluenzaA/H1N1

    SwineInfluenzaA/H1N1CaseInvestigationForm

    County_______________ Institution_____________ DateofReport__/__/__(dd/mm/yy)

    1. PatientInformationName

    AgeSexMF

    Address

    Phone Case#(NSUONLY)

    2. ClinicalDataDateofonsetofillness__/__/__(dd/mm/yy)

    FeverYNCoughYNMyalgiaYNSoreThroatYNProstrationYNPneumoniaYNDyspnoeaYNReyesSynd.YN

    InfluenzaImmunisationHistory

    DateofpresentationtoInstitution__/__/__(dd/mm/yy)

    Haspatienteverhadinfluenzavaccine?YN

    Ifyes,dateoflastdose__/__/__(dd/mm/yy)

    Waspatienthospitalised?YN Hospitalisationdate__/__/__(dd/mm/yy)

    Outcome:SurvivedDied(Date__/__/___)

    3. ExposureHistoryHistoryofTraveltoareasaffectedbyswineflu?

    YN

    Details:(includedatesoftravel)

    Historyofcontactwithpersonsfromareasaffectedby

    swineflu?YN

    Details:(includedatesofcontact)

    Historyofcontactwithpersonswithsevereorunusual

    respiratoryillness?YN

    Details:(includedatesofcontact)

    IsthereaclusterofSimilarCasesinDistrict?YN(Pleasegivedetailsbelowifyes):

    4. LaboratoryDataSpecimen Datecollected DateRecd Condition Test Result DateSent Comment

    Nasal/NPswab

    Throatswab

    5. FinalClassification: ReportedtoCMOSuspectedEpidemiologicallyConfirmedLaboratoryConfirmed Signature


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