Dengue Case Investigation Report
Home address here DENGUE & CHIKUNGUNYA REPORT FORM U.S. Virgin Islands Department of Health SUSPECTED CHIK? Yes No Charles Harwood Complex, 3500 Estate Richmond Christiansted, St. Croix, USVI 00820-4370 Tel. (340) 773-1311 x3241, Fax (340) 718-1508 Case number Specimen # Days post onset (DPO) Type Date Received Specimen # Days post onset (DPO) Type Date Received S1 SAN ID GCODE S2 S3 S4 Please read and complete ALL sections Patient Data Hospitalized due to this illness: No Yes → Hospital Name: Record Number: Name of Patient: Last Name First Name Middle Name or Initial Fatal: Yes No Unk Mental status changes: If patient is a minor, name of father or primary caregiver: Last Name First Name Middle Name or Initial Yes No Unk Home (Physical) Address Physician who referred this case Name of Healthcare Provider: Tel: Fax: Email: Do you want to receive laboratory results via Fax or Email? City: Zip code: - Tel: Other Tel: Residence is close to: Work address: Patient’s Demographic Information Who filled out this form? …
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Home address here DENGUE & CHIKUNGUNYA REPORT FORM U.S. Virgin Islands Department of Health SUSPECTED CHIK? Yes No Charles Harwood Complex, 3500 Estate Richmond Christiansted, St. Croix, USVI 00820-4370 Tel. (340) 773-1311 x3241, Fax (340) 718-1508 Case number Specimen # Days post onset (DPO) Type Date Received Specimen # Days post onset (DPO) Type Date Received S1 SAN ID GCODE S2 S3 S4 Please read and complete ALL sections Patient Data Hospitalized due to this illness: No Yes → Hospital Name: Record Number: Name of Patient: Last Name First Name Middle Name or Initial Fatal: Yes No Unk Mental status changes: If patient is a minor, name of father or primary caregiver: Last Name First Name Middle Name or Initial Yes No Unk Home (Physical) Address Physician who referred this case Name of Healthcare Provider: Tel: Fax: Email: Do you want to receive laboratory results via Fax or Email? City: Zip code: - Tel: Other Tel: Residence is close to: Work address: Patient’s Demographic Information Who filled out this form? Date of Birth: Age: months Sex: M F or Age: years Pregnant: Y N UNK Name (complete) Relationship with patient: Day/Month/Year Weeks pregnant (gestation): Tel: Fax: Email: Must have the following information for sample processing Day/Month/Year How long have you lived in this city? Country of birth Date of first symptom: Date specimen taken: During the 14 days before onset of illness, did you TRAVEL to other cities or countries? First sample Second sample Yes, another country Yes, another city No Unknown WHERE did you TRAVEL? Are there any sick contacts in your household? Yes No PLEASE indicate below the signs and symptoms that the patient had at the time of illness Fever lasting 2-7 days……………...... Fever (>38ºC/101ºF)………………...... Platelets ≤100,000/mm3………..…..... Yes No Unk Evidence of capillary leak Lowest hematocrit (%) Highest hematocrit (%) Lowest serum albumin Lowest serum protein Warning signs Persistent vomiting................................... Abdominal pain/Tenderness………….. Mucosal bleeding ……………………..... Lethargy, restlessness……….…………... Yes No Unk Platelet count: Any hemorrhagic manifestation Petechiae……………………….. Lowest blood pressure (SBP/DBP) / Lowest pulse pressure (systolic - diastolic) Lowest white blood cell count (WBC) Liver enlargement >2cm……………….. Pleural or abdominal effusion…………. Additional symptoms Purpura/Ecchymosis………….. Symptoms Yes No Unk Diarrhea……………………………...…….. Vomit with blood………………. Blood in stool…………………… Nasal bleeding………………… Bleeding gums…………………. Blood in urine…………………... Vaginal bleeding……………… Positive urinalysis…………….... (over 5 RBC/hpf or positive for blood) Tourniquet test Pos Neg Not done Rapid, weak pulse……………... Pallor or cool skin………………. Chills………………………….…… Rash…........................................... Headache……………….………. Eye pain………………………….. Body (muscle/bone) pain……. Joint pain………………………… Anorexia………………………..... Cough…………………………………….… Conjunctivitis…………………………….... Nasal congestion………………………… Sore throat……………………………….... Jaundice……………………….................. Convulsion or coma…………………….. Nausea and vomiting (occasional)….. Arthritis (Swollen joints)………………….. Missed school/work due to this illness. Unable to walk during this illness…….. Today’s date: _______________ Day/Month/Year