“ Philippine integrated Disease Surveillance and Response Case Report Form {a Hand, Foot and Mouth Disease and Severe Enteroviral Disease Name of DRU: POmay Address: xgace Résov Fooarer Anfare| type: ORHU OCHO BGovtHosptal CPrivete Hospital cline | Govt Laboratory Private Laboratory CAkporvSeaport 1. PATIENT INFORMATION Patent Number [Patt First Name Miao Name Taat Name OG- F3- AS Cyrene morjak — Ll0ng Lan10g ‘oF te Address a te of 7 Ie ex Complete ASSESS Om Déiev Faroe r Pac ore op 5 lark ae Daye | OMe Jobin Foenrer Wiz: ¢parE bry (P Norte] Eel | | _ venrs| | valent acmited? OY GN [Date Admited/ | 1A |“02 "2B aia Oat ta) oe we ob | 2072 _\attwness oy _\ey| 22 me ortact Nos wey ou |e Enmore Febrero OR2PY GRO POY Tl CUNIGAL INFORMATION | Fever: ey ON Other signs/symptoms (please tick) ‘Are there any complications? | Date onset: 241 0%) 22 1 Poorioss of appetite ay en Resi OY ON 1 Body mlsise YES, spect Date onset: OF) 87 fo2 1 Sore throat Bipéims fingers Nausea & vorniting Bisoles of feet Buttocks | Diticuty of breathing Working/Final Diagnosis ‘Mouth vloars | Acute Fics Porasi Panu? = OY ON Meningeal itation HEI | characterise: Others, specity: Cimaculopapuler Erpepuiovesicular — |___ | 1. EXPOSURE HISTORY Se Is there a ristory of travel witin 12 wees tan area wih ongoing epidemic of HFMD or EV Osease? CY FN | |e there otter known cases in the community? eyon | Where did exposure probably occur? Day care ‘Community schoo! Dormitory Brome (HealthCare Factives Dothers, speciy | IV, LABORATORY TESTS fa nd Specimen ives, | oatesentto | Date received | Posie, Nego- cere, Date of result um caieced | RITE acRITM |e Net Dore DiThroat swab ‘DVericle swab |[DrRecal swab cc IV. CLASSIFICATION “BSuspected case of HFMD Cl Suspected case of Severe O Died ] Enteroviral Disease | DoProbabie case of HFMD — CIConfimmed case of Severe | Enteroviral Disease Ciconfirmed case of HFMDPhilippine Integrated Disease i) Surveillance and Response Case Report Form offs Hand, Foot and Mouth Disease and Severe Enteroviral Disease Name of ORU D7 DY ‘Address: xboce ohrer Foner Type: ORHU CHO 2Gov'tHospital Private Hospital Clinic Govt Laboratory CiPrivate Laboratory CiArpor/Seaport 1. PATIENT INFORMATION Patient Number Patents Fst Name Tide Name ast Name Ol - Fab~ 2 REY wire LIbN8 LOMOE asia 5 . Sex [Complete Recess) 1 in psior Former Anbive Date ot istic 9,7 ,/9| Beam | Male 7eain FORMER PMheie Wz: Abbe SELELEE) DiNenitn) Fare | Patient admitied?” CY G0 ————~[Date Admitted |_7 J —aa Tata Onset mae |Seen/Consult C_| 22 __|otitness Y \y | 42 | mye ame of vestigate [Gantt Nos 4 \6 \2 EMRE FEORERD OPA PEG OY I. CLINICAL INFORMATION Fever: oY en (Other signa/symptoms (please tick) | Are there any complications? | Date onset: __y_ Poorlloss of appetite oy on Rash: BY ON Body malaise NYES, speaty Date onset: 41 Y 182 Sore throat | Balms Diingers Nausea & voriting 2iSSies of feet Buttocks Dicuty of breathing | WorkingFinal Diagnosis Mouth ulcers | Acute Fiaccid Paralysis | Pan? = OY aN | Meningea! ition Characteristic: Others, spect | Cimaculopapular -E-papuiovesicular | Wl, EXPOSURE HISTORY [ie there @ history of travel within 12 weeks to an area with ongoing epidemic of HFMD or EV Disease? —-« -Y GN | are there other known cases in the community? By oN | where di exposure probably occur? | ODay care (Community School Dormitory | Biome GHealthCare Facilities others, specify | IV. LABORATORY TESTS Result: | Specimen tyes, | dutesertto | Dats recatved | Postves Nepe eect, — | pat ot recut | Date Collected RIM at RTM tive , Not Done — (DThroat swab DVesicie swab mee Rectal swab L 0 Stool pane V. CLASSIFICATION Vi, OUTCOME ‘EStispected case of HFMD 0) Suspected case of Severe O Died Enterovral Disease ToProbable case of HFMO [Confirmed case of Severe Date diet Enterovial Disease Ciconfimed case of HFMDPhilippine integrated Disease Fa Soot oes Case Report Form butt Hand, Foot and Mouth Disease and Severe Enteroviral Disease Name fORU: Dm DV lAddress: § abace Jobiov Fo rater Type: ORHU OCHO Gov't Hospital Private Hospital CIClinic Popae Govt Laboratory OPrivate Laboratory CiAirporySeaport |. PATIENT INFORMATION Pant Raber avons Frat Name Tie Name Test Name O6- 2Y-SF POUCRH CRIVRKDRB PPTULD DPkUOPINE a S al e GOS yp FLOR ToBI FURMIER pune pass aaa | aloe Baer a OMe Jobinc For iiee we pppoe LYLE BNicins| BFemale Breas Palen eariiod? OY GFF [ate Aiea |] 2] “Togs rset Ya | Seonconeut | OY | / | 202 _lortmose 3 _|3/| 2aee! a ar ame owes contact es Trwsetgaion: | f | 7 |datd) LmOOne FEBRERO OR2°OFG FOU CLINICAL INFORMATION Fever: oY en Tote signs/symtoms (please ick) re there any complcatons? | Date onset:__/_/_ O Poorlloss of appetite oY en Rosh; GY ON 1D Body mala IFYES, speoty | Date onset: 9 13/) 2? © Sore throat Erpaims fingers Nausea & voring BSoles of feet OButtocks: Difficulty of breathing Working/Final Diagnosis Mouth ulcers: © Acute Flaccid Paralysis Paint? SY GN 1D. Meningeal ination Characteristic: Others, spect i maculopapular 2rFapulovesicular I EXPOSURE HISTORY Is there a history of travel within 12 weeks to an area with ongoing epidemic of HFMD or EV Disease? ©» «sO Y -N ‘Are there other known cases in the community? ayon Where did exposure probably occur? Oday care ‘Community ‘school Dormitory | GHtome HealthCare Facies Goters, specty IV, LABORATORY TESTS: 1 Specify | incacinee ‘organism Throat swab DVesicie swab Ss Rectal swab [ 1D Stool | V. CLASSIFICATION [2Suspected case of HFMD Cl Suspected case of Severe = Aive G Died Enterovial Disease Probable case of HFMD — C1Confirmed case of Severe Enteroviral Disease CConfirmed case of HFMDPhilippine integrated Disease ‘Surveillance and Response Hand, Foot and Mouth Case Report Form Disease and Severe Enteroviral Disease Name fORU. DD OY Address: boca Jybiar Far0ler ‘Type: GRHU OCHO S6ovt Hospital Private Hospital DClinic Pohase Govt Laboratory Private Laboratory ClArportSeaport 1. PATIENT INFORMATION Patent Number Patients Ft Name ‘idle Name ast Name O¢- LY-60 WT CRECTOFE PETAR DOULUMPMEL (Complete Address = — i je Sex) ate jeiov Ferorer papare mer) 2 [District Days | Sale Jbrey Farner We: hore Meri} Femate ears Paliontsdmiiod? CY GN ~[Date Admited! | _ Waa ar aoe) ISeeniConsut | OF |O/ | Le oF _|2/| 22 faa ae [Name of investigators Investigation: loy Ae | Bel: kmnadre Febrc OFLIYPLC POY CLINICAL INFORMATION Fever: ay ON Other signs/symptoms (please tick) Are there any complications? Date onset, 3/37 /f2 1D Poortoss of appetite oy BN Rash) BY ON © Body malaise YES, specty: Date onset: 3 jF/ X22 1D Sore throat palms Diingers: | Nausea & vomiting ZiSbes of feet Buttocks 1D. Difficulty of breathing Working Final Diagnosis | CiMouth uicers Acute Flaccid Paralysis | | Painful? oY oN D Meningeal irritation EMO Characters: Others, specity: macuiopapular Gpapulovesicuiar il, EXPOSURE HISTORY Js there a history of travel within 12 weeks to an area with ongoing epidemic of HFMD or EV Disease? OY &N ‘Ave there other known cases in the community? By oN ‘Where did exposure probably occur? Oday core Community Dschoo! Dormitory Bome DHealthCare Facilities Others, specify IV. LABORATORY TESTS V. CLASSIFICATION ‘Vi. OUTCOME “‘ZSuspected case of HFMD Cl Suspected case of Severe Alve Died Enteroviral Disease Probable case of HFMD — C1Confirmed case of Severe Date died: | Enteroviral Disease CiConfirmed case of HFMDfa Philippine integrated Disease Surveillance and Response Case Report Form Hand, Foot and Mouth Disease and Severe Enteroviral Disease [Name of ORU: DD may Address: ahaca pobar Fornren pnpue | PE ORHU OCHO EGovtHosptal CPrivate Hospital Cicini Govt Laboratory Private Laboratory CIAirpor/Seaport |. PATIENT INFORMATION Patient Number Pabonta Fest Nae Tidaie Name Tast Name O7-/3-2y DNeab Larter Coupttlo haguicky (Complete Aacross 7 Sex ‘Dichun fester Forever Pohiue [pane I? istic: Days | Mole ehier Former WH ypag OT (50) Suen} Farle [Pailont admived? OV ON [Bate Adria! | 1A] 22) Toate Onset a [SeewConsut | OF P| Lon bes 4 27 | Zed Baa | |] 22 Name of investigators: [Contact Nos. investigation: | OY |/P | £2 Bmmane Febrero OF929Y9LLG OY U. CLINICAL INFORMATION Fever OY ON ‘Other signe/symptoms (please ick) | Are there any complications? | Date onset: 1 Pooriloss of appetite oy GN [Rash: BY ON Body malaise IFYES, specify: Date onset: 4 /7) Ladd D Sore throat = Bpaims fingers | Nausea & voniting ‘soles of feet Buttocks 1D Difficulty of breathing ‘Working/Final Diagnosis ‘Mouth ulcers 1D Acute Flaccid Paralysis | Pain? = OY BN 1D Meningeat itation yrmo | Characteristic: Others, specity | | Chmacuiopapuler Efepuiovesicular | i, EXPOSURE HISTORY Is there a history of travel within 12 weeks to an area with ongoing epidemic of HFMD or EVDisease? = OY EN | | Ave there othr known cases in the community? eyon | Where did exnosure probably occur? ODay care Beommunity Schoo! Dormitory | Home HealthCare Facilities Dotners, specity IV, LABORATORY TESTS aoe Date of result Specimen ee Throat swab ‘GRectal swab =a 1 Stool ee V. CLASSIFICATION Vi OUTCOME: Suspected case of HFMD (I Suspected case of Severe Aive 0 Died Enterovial Disease DProbable case of HFMD Confirmed case of Severe Date dies | Enterovial Disease ‘DContirmed case of HEMD |