VACCINEE PATIENT'S

REGION PROVINCE MUNCITY NAME OF HEALTH FACILITY CODE SURNAME

8 SAMAR CATBALOGAN SAMAR PROVINCIAL HOSPITAL - CALADES

PATIENT'S FIRST DATE OF
AGE SEX COMPLETE ADDRESS ADMITTED?
NAME BIRTH

ZAYN MARGAUX 12 F 11/11/2005 BRY. BAGONGON SIERRA Yes

 DATE OF DATE ONSET NUMBER OF DATE OF FIRST
ADMITTING DIAGNOSIS ADMISSION OF ILLNESS DENGVAXIA DOSES DOSE RECEIVED

DENGUE FEVER NS1 POSITIVE 12/13/2017 12/11/2017 1 06/2016

 DATE OF LAST REGION WHERE THE DENGUE PROVINCE WHERE THE DENGUE
DOSE RECEIVED VACCINE WAS GIVEN VACCINE WAS GIVEN

06/2016 3 BULACAN
 BRAND OF DENGUE
PLACE THE DENGUE NS1 - RDT IgG ELISA IgM ELISA SCREENING KIT (NS1, FEVER? PAST HISTORY
VACCINE WAS GIVEN RESULT RESULT RESULT OF DENGUE
IgG, IgM) USED

PABAHAY ELEM. SCHOOL Positive Negative Negative NS1 Yes No

DENGUE CLINICAL OUTCOME DATE DIED REMARKS
CLASSIFICATION

With Warning Signs Alive/Discharged N/A N/A