Case Report Form
Philippine Integrated Disease
Surveillance and Response
Dengue (ICD 10 Code: A90-A91)
Region:
____________________________
Name of DRU:
_________________________________________________________________
Address:
______________________________________________________
Patient
No.
Response
Codes /
Instructions
Patients Full Name
Indicate First name, Middle name,
Last name
Age
Province: ___________________________
Sex
(F/M)
Age: Indicate
D - days
M - months
Yr. - years
Sex:F - Female
M - Male
Case Definition/Classification:
Dengue without Warning signs.
Suspect
A previously well person with acute febrile illness of 2-7 days dura tion plus two of the following:
Headache, Body malaise, Myalgia, Arthralgia, Retro-orbital
pain, Anorexia, Nausea, Vomiting, Diarrhea, Flushed skin,
Rash ( petecheal, Hermans sign)
Probable
A suspect cases
AND
Laboratory test, at least CBC (leucopenia with or without
thrombocytopenia) and/or Dengue NS1, antigen test or
dengue IgM antibody test (optional)
Confirmed:
- Viral culture isolation,
- Polymerase Chain Reaction
Date of
Birth
Municipality/City: ________________________________________
Type:
RHU CHO Govt Hospital Private Hospital Clinic
Private Laboratory Public Laboratory
Seaport/Airport
Complete Address
Admitted?
Date admitted/seen/
consulted
Date onset
of illness
___/___/___
___/___/___ ___/___/___
___/___/___
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Clinical
Lab
Case
Case
Classifi- classification
cation
Wwith
warning
signs
mm/dd/yy
Specify Street/Purok/Subdivision, House #,
Barangay, Municipality/City, Province
Y - Yes
N- No
mm/dd/yy
mm/dd/yy
N no warning signs
S-Severe
Dengue
S - Suspect
P - Probable
C - Confirmed
Outcome
A - Alive
D - Died
(specify
date)
U - Unknown
Dengue with Warning Signs
Severe Dengue
,A previously well person with acute febrile illness of 2-7 days duration plus
any one of the following:
A previously well person with acute febrile illness of 2-7 days duration and
any of the clinical manifestations for dengue with or without warning signs,
Plus any of the following:
Severe plasma leakage leading to
- Shock
- Fluid accumulation with respiratory distress
Severe bleeding
Severe organ impairment
- Liver: AST or ALT >1000
- CNS: e.g. seizures, impaired consciousness
- Heart: e.g. myocarditis
- Kidneys: e.g. renal failure
- Abdominal pain or tenderness
- Persistent vomiting
- Clinical signs of fluid accumulation
- Mucosal bleeding
- Lethargy, restlessness
- Liver enlargement
- Laboratory: increase in Hct and/or decreasing platelet count
Case Report Form
Philippine Integrated Disease
Surveillance and Response
Patient
No.
Response
Codes /
Instructions
Patients Full Name
Indicate First name, Middle name,
Last name
Dengue (ICD 10 Code: A90-A91)
Age
Sex
(F/M)
Age: Indicate
D - days
M - months
Yr. - years
Sex:F - Female
M - Male
Date of
Birth
Complete Address
Admitted?
Date admitted/seen/
consulted
Date onset
of illness
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___/___/___ ___/___/___
___/___/___
___/___/___ ___/___/___
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___/___/___ ___/___/___
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___/___/___ ___/___/___
___/___/___
___/___/___ ___/___/___
___/___/___
___/___/___ ___/___/___
___/___/___
___/___/___ ___/___/___
mm/dd/yy
Specify Street/Purok/Subdivision, House #,
Barangay, Municipality/City, Province
Y - Yes
N- No
mm/dd/yy
mm/dd/yy
Clinical
Case
Classification
Lab
CaseClassifi
cation
W - with
Warning
signs
N no warning signs
SSevere
Dengue
S Suspect
P- Probable
C
confirmed
Outcome
A - Alive
D - Died
(specify
date)
UUnknown
