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RISK FACTOR ASSESSMENT for Dengue fever and Dengue Hemorrhagic fever

FOR 17 YEARS OLD AND BELOW

INSTRUCTION: Check the following boxes that correspond to your answer AND PLEASE INDICATE DETAILS. (at least 3 risk factors will mean high risk for the disease)

Infants and Poor Stagnant water Living in a Prior infection with a Travelling or
NAME ADDRESS AGE SEX WEIGHT children sanitation in and outside crowded home With compromised dengue fever virus living in tropical
the house immune system countries

Note: the RFA checklist will depend on the leading cause of morbidity and mortality among adults and children in your community.

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