Province of Benguet

Municipality of Itogon Page 1

Municipal Health Services Office

Case Report Form

DENGUE (ICD 10 Code: A97.0-A97.2, A97.9)
Name of DRU: _____________________________________

Date of
Civil Indigenous
Patient No. Patients Full Name Age Sex Date of Birth Complete Current Address Complete Permanent Address Cellphone number Status
Consulted FIRST Place of Consultation
People
consultation

LAST:
ITG-2023-0-
FIRST:
__________
_________ MIDDLE:

ITG-2023-0- LAST:
__________ FIRST:
_________
MIDDLE:

ITG-2023-0- LAST:
__________ FIRST:
_________
MIDDLE:

ITG-2023-0- LAST:
__________ FIRST:
_________
MIDDLE:

ITG-2023-0- LAST:
__________ FIRST:
_________
MIDDLE:

Age: Indicate
D-Days S- Single
Indicate M-Months M-Married
Y- Yes
Response Last name Yr- Years Specify House # Street/Purok/Subdivision, Specify House # Street/Purok/Subdivision, Sep- Please specify
mm/dd/yy N-No mm/dd/yy Name of Facility
Codes/Instructions First name, Barangay, Municipality/City, Province, Region Barangay, Municipality/City, Province, Region Separated what tribe
Middle name SEX: W-
F-Female Widowed
M-Male
Clinical Classification: Case Classification:
A. DENGUE WITHOUT WARNING SIGNS B. DENGUE WITH WARNING SIGNS C. SEVERE DENGUE SUSPECT: A previously well person with acute febrile illness of 2-7 days
Person with acute febrile illness of 2-7 days duration Person with acute febrile illness of 2-8 days duration Dengue with at least one of the following criteria: duration with clinical signs and symptoms of dengue.
plus two of the following: with any of the following:
*Severe plasma leakage leading to shock and/or fluid
*Headache *Nausea *Abdominal pain or tenderness *Restlessness accumulation with respiratory distress PROBABLE: A suspected case with positive dengue IgM antibody test.
*Body malaise *Vomiting *Persistent vomiting *Liver enlargement≥2 cm *Severe bleeding as evaluated by clinician
*Myalgia *Diarrhea *Clinical fluid accumulation *Lethargy *Severe organ involvement such as AST or ALT≥1000, CONFIRMED: A suspected case with positive results for:
*Arthralgia *Flushed skin (ascites, pleural effusion) *Laboratory: increase in HCT concurrent impaired consciousness and failure of heart and other organs. * Viral culture isolation. or
*Retro-orbital pain *Skin rash (petechial, Herman’s sign) *Mucosal bleeding with rapid decrease in platelet count * Polymerase Chain Reaction (PCR); or
*Anorexia * Dengue NS1 antigen test
Name and Signature of Interviewer: _____________________________ Date : __________________________

Province of Benguet Page 2

 Municipality of Itogon
Municipal Health Services Office

Case Report Form

DENGUE (ICD 10 Code: A97.0-A97.2, A97.9)
Date Date of Vaccinate
Date of FIRST Date of LAST NS1 IgG IgM PCR
admitted/ onset d with Clinical Case
Out-
Patient No. Patients Full Name Admitted? illness Vaccination Vaccination Classifica Classifi
seen/ Dengue tion cation come
(FIRST (if yes) (if yes) Result Date Done Result Date Done Result Date Done Result Date Done
consulted Symptoms)
vaccine?

ITG-2023-0- LAST:
__________ FIRST:
_________
MIDDLE:

ITG-2023-0- LAST:
__________ FIRST:
_________
MIDDLE:

ITG-2023-0- LAST:
__________ FIRST:
_________
MIDDLE:

ITG-2023-0- LAST:
__________ FIRST:
_________
MIDDLE:

ITG-2023-0- LAST:
__________ FIRST:
_________
MIDDLE:

N-No P: Positive P: Positive S: A: Alive

P: Positive P: Positive
warning N: Negative N: Negative Suspect D: Died
N: Negative N: Negative
Indicate signs E:Equivocal E:Equivocal P: Specify
E:Equivocal E:Equivocal
Response Last name Y-Yes Y-Yes W-With PR:Pending PR:Pending Probabl date of
mm/dd/yy mm/dd/yy mm/dd/yy mm/dd/yy PR:Pending mm/dd/yy PR:Pending mm/dd/yy mm/dd/yy mm/dd/yy
Codes/Instructions First name, N-No N-No warning Result Result e death in
Result Result
Middle name signs N/A: Not N/A: Not C: mm/dd/
N/A: Not N/A: Not
S: Severe done done Confirm yyyy
done done
Dengue ed

Name of DRU: _____________________________________

Clinical Classification: Case Classification:
A. DENGUE WITHOUT WARNING SIGNS B. DENGUE WITH WARNING SIGNS C. SEVERE DENGUE SUSPECT: A previously well person with acute febrile illness of 2-7 days
Person with acute febrile illness of 2-7 days duration Person with acute febrile illness of 2-8 days duration Dengue with at least one of the following criteria: duration with clinical signs and symptoms of dengue.
plus two of the following: with any of the following:
*Severe plasma leakage leading to shock and/or fluid
*Headache *Nausea *Abdominal pain or tenderness *Restlessness accumulation with respiratory distress PROBABLE: A suspected case with positive dengue IgM antibody test.
*Body malaise *Vomiting *Persistent vomiting *Liver enlargement≥2 cm *Severe bleeding as evaluated by clinician
*Myalgia *Diarrhea *Clinical fluid accumulation *Lethargy *Severe organ involvement such as AST or ALT≥1000, CONFIRMED: A suspected case with positive results for:
*Arthralgia *Flushed skin (ascites, pleural effusion) *Laboratory: increase in HCT concurrent impaired consciousness and failure of heart and other organs. * Viral culture isolation. or
*Retro-orbital pain *Skin rash (petechial, Herman’s sign) *Mucosal bleeding with rapid decrease in platelet count * Polymerase Chain Reaction (PCR); or
*Anorexia * Dengue NS1 antigen test

Name and Signature of Interviewer: _____________________________ Date : ___________________