Epidemic-prone Disease Case Report Form Version 2022

Case Surveillance Chikungunya Viral Disease (ICD 10 Code: A92.0)

Region: REGION 4B
____________________________ ORIENTAL MINDORO
Province: ___________________________ POLA
Municipality/City: ________________________________________
POLA RURAL HEALTH UNIT
Name of DRU: _________________________________________________________________ Type:X⃞RHU ⃞CHO/MHO/PHO ⃞Gov’t Hospital ⃞Private Hospital ⃞Clinic
Address: BAYANAN, POLA, ORIENTAL MINDORO
_________________________________________________________________ X
Type of site: ⃞Sentinel ⃞Non-sentinel
CHRISTINE P. AÑO
Name of Interviewer: _____________________________________________________________

COMPLETE CURRENT COMPLETE Date

Date Date of
Patient PATIENT’S FULL NAME Date of ADDRESS PERMANENT admitted/
Age Sex Admitted? onset of Fever Arthralgia Onset of
No. Last name, First name, Middle name Birth (place of residence within 30 ADDRESS seen/
illness Arthralgia
days) consulted
SITIO PANAY, BRGY. BATUHAN,
ROASA, JOHN PAUL MARTINEZ 23YR M 12 02 97
____/____/____
POLA, ORIENTAL MINDORO
SITIO PANAY, BRGY. BATUHAN,
POLA, ORIENTAL MINDORO N 07 04 22
____/____/____ 07 01 22
____/____/____ Y Y 07 02 22
____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

Age: Indicate
D - days
M - months Specify House or Building Specify House or Building
Indicate Last Name, followed by First name, Y - Yes Y - Yes Y - Yes
Yr. - years mm/dd/yyyy number, Street, Barangay, number, Street, Barangay, mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy
and Middle name N- No N- No N- No
Municipality/City, Province Municipality/City, Province
Sex:F - Female
M - Male

Case Classification
Suspect Confirmed
Acute onset of fever (with a temperature of >38.5°C or hot to touch), and A case meeting laboratory criteria, irrespective of the clinical presentation:
severe/incapacitating arthralgia not explained by other medical conditions. At least one of the following tests in the acute phase:
- Virus isolation
- Presence of viral RNA by RT-PCR
Probable - Presence of virus specific IgM antibodies in single serum sample collected in acute or
Acute onset of fever (with a temperature of >38.5°C or hot to touch), and convalescent stage.
severe/incapacitating arthralgia not explained by other medical conditions and
residing or having visited epidemic areas, having reported transmission
within 15 days prior to the onset of symptoms.
 Epidemic-prone Disease Case Report Form Version 2022
Case Surveillance Chikungunya Viral Disease (ICD 10 Code: A92.0)

Region: REGION 4B
____________________________ ORIENTAL MINDORO
Province: ___________________________ POLA
Municipality/City: ________________________________________
POLA RURAL HEALTH UNIT
Name of DRU: _________________________________________________________________ Type:X⃞RHU ⃞CHO/MHO/PHO ⃞Gov’t Hospital ⃞Private Hospital ⃞Clinic
Address: BAYANAN, POLA, ORIENTAL MINDORO
_________________________________________________________________ Type of site: X
⃞Sentinel ⃞Non-sentinel
CHRISTINE P. AÑO
Name of Interviewer: _____________________________________________________________

Serology IgG Is there history

Serology IgM RT-PCR Viral Isolation
ELISA of travel within Case
PATIENT’S FULL NAME 15 days to
Patient No. Classific Outcome
Last name, First name, Middle name known ongoing
Result Date done Result Date done Result Date done Result Date done epidemic ChikV ation
Case?

07 04 22 N C A
ROASA, JOHN PAUL MARTINEZ P ____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

____/____/____ ____/____/____ ____/____/____ ____/____/____

P: Positive P: Positive P: Positive S: Suspect A: Alive

P: Positive Y:Yes (specify
N: N: Negative N: Negative P: Probable D: Died
N: Negative
Indicate Last Name, First name, Middle name mm/dd/yyyy Negative mm/dd/yyyy I: mm/dd/yyyy I: mm/dd/yyyy place)
I:Indetermi
I:Indetermi Indetermina Indetermina C: (specify date
nate N: No
nate te te Confirmed of death)

Case Classification

Suspect Confirmed
Acute onset of fever (with a temperature of >38.5°C or hot to touch), and A case meeting laboratory criteria, irrespective of the clinical presentation:
severe/incapacitating arthralgia not explained by other medical conditions. At least one of the following tests in the acute phase:
- Virus isolation
Probable - Presence of viral RNA by RT-PCR
Acute onset of fever (with a temperature of >38.5°C or hot to touch), and - Presence of virus specific IgM antibodies in single serum sample collected in acute or
severe/incapacitating arthralgia not explained by other medical conditions and convalescent stage.
residing or having visited epidemic areas, having reported transmission
within 15 days prior to the onset of symptoms.