Philippine Integrated Disease Case Report Form

Surveillance and Response

Acute Bloody Diarrhea
Region: ____________________________ Province: ___________________________ Municipality/City: ________________________________________
Name of DRU: _________________________________________________________________ Type: ⃞RHU ⃞CHO ⃞Gov’t Hospital ⃞Private Hospital ⃞Clinic
Address: ______________________________________________________ ⃞Private Laboratory ⃞Public Laboratory ⃞Seaport/Airport

Date Admit-
Admit- Date onset Out-
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address ted/seen/ Lab result
ted? of illness come
consulted

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Age: Indicate P - Positive A - Alive
D - days (specify D - Died
Response
Indicate First name, Middle name, M - months Specify Street/Purok/Subdivision, House #, Barangay, Y - Yes organism) (specify
Codes / mm/dd/yy mm/dd/yy mm/dd/yy
Last name Yr. - years Municipality/City, Province N- No N - Negative date)
Instructions
Sex:F - Female ND - Not done U-
M - Male U - Unknown Unknown

Case Definition:

 A person with acute diarrhea with visible blood in the stool.

Note: Laboratory culture of stools may be used to confirm possible outbreaks of specific diarrhea, such as S. dysenteriae type 1, but is not necessary for case definition.

 Case classification: Not applicable

 Philippine Integrated Disease Case Report Form
Surveillance and Response Acute Bloody Diarrhea

Date Admit-
Admit- Date onset Out-
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address ted/seen/ Lab result
ted? of illness come
consulted

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

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Age: Indicate P - Positive A - Alive
D - days (specify organ- D - Died
Response
Indicate First name, Middle name, M - months Specify Street/Purok/Subdivision, House #, Barangay, Y - Yes ism) (specify
Codes / mm/dd/yy mm/dd/yy mm/dd/yy
Last name Yr. - years Municipality/City, Province N- No N - Negative date)
Instructions
Sex:F - Female ND - Not done U-
M - Male U - Unknown Unknown