60-Day Follow-up Examination for Acute Flaccid Paralysis (AFP) Case
Date of onset of weekness/paralysis ( Day/Monthyear )] OB /O6 iQ
F
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ir tay low up ceamination condi? 7 ‘TCe) Ts
of canon
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fiver wane wating [ve [wor [ve No | Gat Ghange | ye | No
[Wher moving ibs Ray edSGay
[Able to sit, crawl of stand with or without support = 5
[Bearing weight on Jegs (mention whether on one or both legs) =
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Fees =| | ae is | Is is | os 7
js eee Dene maperae, teeecranes ba | Biceps Biceps S S
a pa [i
[rowel scores, Mheranad reso ted ve Nee
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semen OM [Gaba Wop [carp Dake Wikece (Siea| Dia
Plantats emnarapome
|Ascending/ descending pattern of paralysis (as compared to inuar investigation) —
= AN
Residual Weakness/paralysis im
Diagnosis, if case does not look like a polio case: — fate Chane Hs - er
SLBA aR
[Bret clinical notes in support of your final diagnosissit discarded as non-poti, Ces
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