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Case Investigation Form Version as of:

03/22/2018
(Surveillance for Dengue Deaths and AEDV)
Type of Reporting Unity:
Name of Reporting Unit:  RHU  CHO  Gov’t Hospital  Private Hospital
 Clinic  Gov’t Laboratory  Private Laboratory  Airport/Seaport
Address: (Street No., Street Name, Barangay, Municipality/City, Province, Region)

I. PATIENT
INFORMATION First Name Middle Name Last Name

Complete Address: (Street No., Street Name, Barangay, Municipality/City, Province, Region

Sex:  Male Date of Birth: MM/ DD/ YYYY Age in: Patient’s Number
 Female  Months Days  Years
II. DENGUE VACCINE DETAILS
Place of Vaccination Vaccinator
Dose Date of
No. Vaccinati Name of
on Facility
Receive MM/ DD/
Type of Street Number
Vaccinated Municipality/City Province Region
d YYYY Facility and Name
(Sch, Clinic or
Community, RHU)
 School MD RN
__/__/__  Comm Midwife
D1 __  Priv.
RHU
 School MD RN
__/__/__  Comm Midwife
D2 __  Priv.
RHU
 School MD RN
__/__/__  Comm Midwife
D3 __  Priv.
RHU
III. HISTORY OF PRESENT ILLNESS
__/__/____
Date onset of present illness MM/ DD/ YYYY
Date of Date of
Signs and Symptoms Onset Onset
(MM/DD/
Signs and Symptoms (MM/DD/
YYYY ) YYYY)
Yes No Fever (2-7 days duration) Ye N
Mucosal Bleeding
s o
Yes No Headache Ye N Lethargy
s o
Yes No Body Malaise Ye N Restlessness
s o
Yes No Arthralgia Ye N Diarrhea
s o
Yes No Myalgia Ye N Liver Enlargement
s o
Yes No Retro-orbital Pain Ye N Increased HCT
s o
Yes No Anorexia Ye N Decreasing Platelet count
s o
Yes No Nausea Ye N Shock
s o
Ye N Fluid accumulation w/
Yes No Vomiting
s o Respiratory Distress
Yes No Diarrhea Ye N Severe Bleeding
s o
Yes No Flushed Skin Ye N Liver: AST or ALT>1000
s o
Rash (petechial, Herman’s Ye N CNS: Seizures, impaired
Yes No
Sign) s o consciousness
Yes No Abdominal pain or Ye N Heart: Myocarditis
tenderness s o
Clinical Signs of fluid Ye N Renal Failure
Yes No
accumulation s o
Consulted? Date of Place of Consultation Name and Complete Address of Consultation
Yes No Consultatio RHU Gov’t Hosp
n Private Clinic Private Hosp
 Admitted Date of Place of Admission Name and Complete Address of Admission
Yes No Admission  Private Clinic Gov’t Hosp
 Private Hosp
Referred from Date of Place Referred Name and Complete Address Referred
other Health Referral  Private Clinic Gov’t Hosp
facility/ (MM/DD/  Private Hosp
YYYY)
Hospital?
Yes No

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Version as of:
03/22/2018

IV. RELEVANT PATIENT INFORMATION PRIOR TO IMMUNIZATION

History of allergy Remarks
Yes No
Specify: a) _____________________ b) _____________________
History of Asthma Yes No
Pre-existing illness / congenital disorder
Yes No
Specify: a) _____________________ b) _____________________
History of hospitalization in last 30 days (indicate the cause) Yes No
Recent history of trauma (indicate date, time and site) Yes No
Was the patient on any concurrent medication for any illness?
(If YES, indicate name of drug, indication, doses and date in the remarks) Yes No
Specify: __________________________________________________
Family History of similar event
Yes No
If YES, Specify: __________________________________________
V. LABORATORY RESULT ON ADMISSION (if Admitted)
Dengue Test Hematology Urinalysis Chest X-Ray/ Ultrasound
(Lung, Abdomen)
Specimen Date Result Brand Date Collected: Date Collected: Date Collected: __/__/____
specimen (+) / (-) / __/__/____ __/__/____ and result
Indeterminate
collected and result and result
NS1 WBC pH Impression:
IgG RBC Sp Gravity
IgM Platelet RBC
PCR Hct Pus Cells
Hgb Bacteria
Seg
Other
Attach copies of ALL available laboratory and diagnostic imaging results/plates once available.
VI. EXAMINATION** DETAILS
Source of Information
 Parent/Guardian  Attending physician 
Nurse  Midwife
Mode of examination
 Interview  Medical records  Physical Examination  Laboratory Result
 Verbal autopsy, If from Verbal autopsy, please mention the source: _______________________________________
Name and Designation of person who first examined the patient: ________________________________________
Date examined:__/__/____
VII. Diagnosis
Admitting Diagnosis:
Working/Final Diagnosis:
Condition at Investigation:  Alive  Recovering  Recovered
 With Permanent Disability, Specify: ___________________________________________________
 Died, Date of Death __/ __/ ____
If Yes, Specify place Autopsied:
Autopsy Conducted?  Health Facility? __________________________________________________________________

Yes No (Complete Address)

 Other Places? __________________ _______________________________________________
(Complete Address
VIII. PARENT/GUARDIAN DETAILS
First Name Middle Name Last Name
Complete Address: Contact number:
IX. Community Investigation
Any known similar events reported recently in the locality/community? Yes No  Unknown
a. If YES, describe:
b. How many events/episodes?
Of those affected, how many are: _______Vaccinated _______Not Vaccinated _______Unknown
Specify, other significant findings in the community if there are any:

Data Collector: __________________________ Contact#:__________________________

Email address: ___________________________ Date Form Filled-up: ___/___/____ MM/DD/YYYY