Federal Ministry of Health - INFLUENZA CASE REPORT FORM
To be filled for suspect, probable or Confirmed case
Reporting Site Health Facility (Hospital/Clinic/Camp)
Region/Zone
Woreda
Patient Out-patient In- Patient ID Number :
Register Patient's name
general Residence: Woreda and Kebele
information Age (Years) : Sex (M or F)
If female, is she currently pregnant? (Yes/No/Don't know)
Occupation
Date first seen at a health facility for this disease (dd/mm/yyyy)
Date of Admission if Inpatient (dd/mm/yyyy)
Date of onset of symptoms (dd/mm/yyyy)
Fever Cough Sore throat Difficulty in breathing Diarrhea Vomiting
Specify other signs and symptoms if any
Risk and Previously vaccinated against Flu? YES NO
Severity If yes, specify year of Flu vaccination
Factors List places visited (travel) during the past 7 days
Visited places with known lab confirmed pandemic influenza cases ?
YES NO
Contact with suspected or confirmed Flu patient(s)? YES NO
Contact with sick or dead animals (wild or domestic)? (Yes or No) YES NO
Person living with HIV? YES NO Unknown
Malnutrition? YES NO
Lab Type of Specimen taken:
information Lab test(s) Performed:
Lab results : A(H5), A(H3), A (H1), New Influenza A/H1 (N1), B virus, Untypable, Not detected, Pending
Result:
Treatment and Treatment :
outcome Outcome (Cured, Died, Transferred out, Lost to follow-up, Still under treatment):
Date of discharge/death (dd/mm/yyyy)
Final Classification (Confirmed / Probable / Suspect / Not a case)
Number of contacts to follow-up
Reporting Officer : Name ________________________________________ Tel________________________________
Other Comments and remarks
Date of last update of this record (dd/mm/yyyy)
