Province of Benguet

Municipality of Itogon
Municipal Health Services Office

Case Report Form

Influenza-like Illness
Name of DRU: _____________________________________ Date : _______________________
Address: __________________________________________
Hx of
travel Date Received
If yes, Date of Date of
Patient Date of Civil Complete Permanent Cellphone abroad Admi admitted/ Anti- Date of last Laboratory Classifi- Out
Patients Full Name Age Sex Specify IP onset of specimen Result
No. Birth Status Address number for the tted? seen/ influenza vaccination Done cation come
last 21 where? Illness vaccine collection
consulted
days
LAST:
ITG-
2023- FIRST:
0______
______ MIDDLE:

ITG- LAST:
2023-
0______ FIRST:
______
MIDDLE:

ITG- LAST:
2023-
0______ FIRST:
______
MIDDLE:

ITG- LAST:
2023-
0______ FIRST:
______
MIDDLE:

ITG- LAST:
2023-
0______ FIRST:
______
MIDDLE:

Age: Indicate
D-Days S- Single
M- Y- Yes A-Alive
Indicate M-Months
Response Married Specify House # N-No Y- Yes Isolation PCR; S-Suspect D-Died
Last name Yr- Years Y- Yes Y- Yes Specify
Codes/Instruc mm/dd/yy Sep- Street/Purok/Subdivision, Barangay, Place of Travel (Please mm/dd/yy mm/dd/yy N-No mm/dd/yy mm/dd/yy Serology; Viral C- (specify
First name, N-No N-No Organism
tions Separated Municipality/City, Province, Region Specify Culture Confirmed date
Middle name SEX: W- tribe) died)
F-Female Widowed
M-Male
Case Definition and Classification: Laboratory Confirmation:
 Suspected case: A person with acute respiratory infection, with measured fever of 38 degrees Celsius and cough with onset within the last 10 days. Virus isolation of Polymerase Chain Reaction (PCR) of swab or aspirate from the suspected individual or direct detection influenza
 Confirmed case: a suspect ILI case who has a laboratory confirmation of influenza virus infection, using one of the following criteria: viral antigen or 4-fold rise in antibody titter between early and late serum.
- Virus isolation - molecular diagnostic test
** Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient’s incapacity, may constitute non-cooperation punishable under the Republic Act No. 11332.

Name and Signature of Interviewer: _____________________________ Date : __________________________