Case Report Form Page Number: 1 of 2 1

Dengue (ICD 10 Code: A90-A91) Revision Number: 2020

DOH-EB-PHSD-01 Effectivity:
Region: NCR _ Province: NCR Municipality/City:
Name of DRU: CRUZ- DALIDA HOSPITAL INCORPORATION Type: ⃞RHU ⃞CHO/MHO/PHO ⃞Gov’t Hospital ⃞Private Hospital ⃞Clinic
Address: 1025 F. SALVADOR ST. JORDAN PLAINS SUBD BRGY. STA, MONICA, . NOVALICHES, QUEZON CITY
Name of interviewer: JOCELYN BELDA PRIVATE HOSPITAL

COMPLETE CURRENT ADDRESS

COMPLETE PERMANET
(place of residence within 30
PATIENT’S FULL NAME ADDRESS Indigeno Date admitted/
Sex days) Civil Consult Date of First Place of Admit Date onset of illness
Patient No. Last name, First name, Middle Age Date of Birth House/Building #, Street, us seen/
(F/M) House/Building #, Street, Status ed? consultation Consultation -ted? ((FIRST symptom/s))
name Barangay, Municipality/City, People consulted
Barangay, Municipality/City,
Province
Province

14568 ZAMORA MARK ROLAND 35 DAYS CHILD NITANG AVERNUE 005 MARGARITA NITANG AVENUE 005 MARGARITA CHILD NO YES CRUZ-DALIDA YES
06/16//14 / 7/18/23 7/15/23
1 MONTH ST. BRGY. GULOD NOVALICHES, ST. BRGY. GULOD NOVALICHES, 7/18/23 HOSPITAL
MARCELINO 09 Y/O QUEZON CITY QUEZON CITY INCORPORATION
/ /

/ /

/ /

/ /

/ / /

Age: S-Single
Indicate M-Married
Specify House or Building number,
Response D - days Sex: Specify House or Building number,
Codes /
Indicate Last Name, followed by
F - Female MM/DD/YY
Street, Barangay, Municipality/City,
Street, Barangay, Municipality/City,
Sep- Y - Yes
MM/DD/YY Name of Facility
Y - Yes
MM/DD/YY MM/DD/YY
First name, and Middle name M - months Province, Region N- No N- No
Instructions Yr. - years M - Male Province, Region Separated
W-
Widowed

Clinical Classification Case Classification

A. DENGUE WITHOUT SUSPECT

WARNING SIGNS B. DENGUE WITH WARNING SIGNS C. SEVERE DENGUE A previously well person with acute febrile illness of 2-7 days duration
Person with acute febrile illness of 2-7 days duration plus two of the with clinical signs and symptoms of dengue
following: Person with acute febrile illness of 2-7 days duration with any of the Dengue with at least one of the following criteria:
following:  Severe plasma leakage leading to shock and/or fluid accumulation

 Headache  Abdominal pain or tenderness  Liver enlargement >2 cm with respiratory distress PROBABLE: A suspected case with positive dengue IgM antibody test
 Nausea  Laboratory: increase in HCT
 Body malaise  Persistent vomiting  Severe bleeding as evaluated by clinician
 Myalgia  Vomiting concurrent with rapid decrease CONFIRMED: A suspected case with positive results for:
 Clinical fluid accumulation  Severe organ involvement such as AST or ALT >1000, impaired
 Arthralgia  Diarrhea in platelet count  Viral culture isolation, or
 Flushed skin (ascites, pleural effusion) consciousness and failure of heart and other organs.
 Retro-orbital pain  Mucosal bleeding  Polymerase Chain Reaction (PCR), or
 Skin rash (petecheal,  Dengue NS1 antigen test
Herman’s sign)  Lethargy
 Anorexia  Restlessness
**requires strict observation and medical intervention
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
 Case Report Form Page Number: 1 of 2 2
Dengue (ICD 10 Code: A90-A91) Revision Number: 2020
DOH-EB-PHSD-01 Effectivity:

Region: NCR _ Province: NCR Municipality/City: QUEZON CITYT

Name of DRU: CRUZ-DALIDA HOSPITAL INCORPORATION Type: ⃞RHU ⃞CHO/MHO/PHO ⃞Gov’t Hospital ⃞Private Hospital ⃞Clinic
Address: 1025 F. SALVADOR ST. JORDAN PLAINS SUBD. BRGY STA. MONICA NOVALICHES, QUEZON CITY
Name of interviewer: JOCELYN BELDA PRIVATE HOSPITAL
NS1 IgG ELISA IgM ELISA PCR

PATIENT’S FULL NAME Vaccinated Date First Vaccinated Date Last Vaccinated
Clinical Case
Patient No. Last name, First name, Middle with Dengue with Dengue Vaccine (If with Dengue Vaccine (If
Classification Classification
Outcome
name Vaccine vaccinated vaccinated Result Date done Result Date done Result Date done Result Date done

14568 ZAMORA MARK ROLAND NO CONFIRMED ALIVE

N/A N/A 7/20/23 N/A
WITH POSITIVE N/A N/A N/A
N/A N/A
MARCELINO WARNING
SIGNS
/ /

/ / / / / / / / / / / /

/ / / / / / / / / / / /

/ / / / / / / / / / / /

/ / / / / / / / / / / /

P:
P: Positive
N: No warning Positive
N:
signs N: P: Positive P: Positive
Negative
Response W: With Negative N: Negative N: Negative S: Suspect A: Alive
Indicate Last Name, followed by First Y - Yes E:
Codes / MM/DD/YY MM/DD/YY warning E: MM/DD/YY MM/DD/YY E: Equivocal MM/DD/YY E: Equivocal MM/DD/YY P: Probable D: Died (specify date
name, and Middle name N- No Equivocal
Instructions signs Equivocal PR: Pending PR: Pending C: Confirmed of death)
S: Severe PR: PR:
Pending Result Result
Dengue Pending
Result
Result

Clinical Classification Case Classification

A. DENGUE WITHOUT WARNING SIGNS SUSPECT
Person with acute febrile illness of 2-7 days duration plus two of the B. DENGUE WITH WARNING SIGNS C. SEVERE DENGUE A previously well person with acute febrile illness of 2-7 days
following: Person with acute febrile illness of 2-7 days duration with any of the Dengue with at least one of the following criteria: duration with clinical signs and symptoms of dengue
following:  Severe plasma leakage leading to shock and/or fluid accumulation PROBABLE: A suspected case with positive dengue IgM

 Headache  Retro-orbital pain  Skin rash (petecheal,  Abdominal pain or tenderness  Lethargy
 Nausea
 Body malaise Herman’s sign)  Persistent vomiting
 Vomiting
 Myalgia  Clinical fluid accumulation (ascites, pleural effusion)
 Diarrhea
Arthralgia
 Anorexia  Mucosal bleeding
Flushed skin
 Restlessness
**requires strict observation and medical intervention
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
 Liver with respiratory distress antibody test
enlargement >2  Severe bleeding as evaluated CONFIRMED: A suspected case
cm
by clinician with positive results for:
 Laboratory:
 Severe organ involvement  Viral culture isolation, or
increase in HCT
such as AST or ALT >1000,  Polymerase Chain Reaction
concurrent with
impaired consciousness and (PCR), or
rapid decrease
failure of heart and other organs.  Dengue NS1 antigen test
in platelet count

 Anorexia  Restlessness
**requires strict observation and medical intervention
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