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Measles Case Reporting Form I.Case Identification/ Demographic Details

This document contains a measles case reporting form with sections for identifying information of the patient, including name, demographic details, and contact information. There are also sections for vital signs, background information like vaccination history and potential exposures, clinical details of symptoms and complications, specimen collection details if performed, and discharge details. The form is used to document details of suspected and confirmed measles cases.

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88 views2 pages

Measles Case Reporting Form I.Case Identification/ Demographic Details

This document contains a measles case reporting form with sections for identifying information of the patient, including name, demographic details, and contact information. There are also sections for vital signs, background information like vaccination history and potential exposures, clinical details of symptoms and complications, specimen collection details if performed, and discharge details. The form is used to document details of suspected and confirmed measles cases.

Uploaded by

Activity Manager
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ID: □□□□□□ □□□□ MEASLES CASE REPORTING FORM

I.CASE IDENTIFICATION/ DEMOGRAPHIC DETAILS


Patient name Father’s name Family card number Ethinicity
National
 Forcibly-Displaced
Myanmar National
 Other
Occupation Phone: Male Female Pregnant
School name, if applicable:
Date of examination: (dd/mm/yy) ___/_______/___________
If date of birth unavailable please indicate age in month or years: Date of birth
Age: (Years) (Months) ____ /____/________
Mahji name Mahji phone Mosque name Imam name

Address Information
For Forcibly-Displaced Myanmar case Zone Block House number

For National case Village Union / Ward Upazila District

II. VITAL SIGNS ON INITIAL EXAMINATION:


Date of examination (dd/mm/yy) ___/_______/___________
Temperature (°C)
III. BACKGROUND INFORMATION:
Measles / MR / MMR containing Contact with known case of measles/similar illness in 7-18 preceding days
vaccine doses  Yes  No  Unknown
Number of total doses If yes, details ______________
 Zero  1  2  Unknown
Number of persons living in the household? _____
Date of last vaccination (dd/mm/yy)
______ /__________ /___________ Other people with similar illness in the family?  Yes  No
 Vaccination card  Self-reported If yes, details_________________

Vitamin A received? Attended health care facility in last 18 days:  Yes  No


 Yes  No  Unknown If Yes, date: ____ /____ /______ Location:________________

Period of communicability: usually 5 days prior to rash onset until 4 days after the onset of
the rash.
IV. CLINICAL DETAILS
Symptoms Complications:
 Fever, Date onset fever: ______ /_____/________  Diarrhea
 Rash, Date onset of rash: ______ /_____/________  Pneumonia
 Cough  Encephalitis
 Coryza (runny nose)  Meningitis
 Conjunctivitis (red, watery eyes)  Serious eye disorders
 Koplik spots (tiny white spots inside the mouth)  Ear infection
 Other, specify ____________  Febrile seizures
 Other, specify ____________

Version: 19 January 2018


ID: □□□□□□ □□□□
Was patient admitted?
 Yes  No Date of admission: (dd/mm/yy) ______ /________/___________

VI. SPECIMEN COLLECTION


Specimen collection done?  Yes  No
Date of collection: (dd/mm/yy):
_____/______/________
Type of sample:  Blood
 Nasalpharygeanl swab
 Urine
Lab results  Positive  Undetermined
 Negative  Not processed
Date of results: (dd/mm/yy):
____/______/________

VII. DISCHARGE DETAILS


Date of Discharge
____ /________/_________
Outcome at discharge
 Recovered
 Death ……………………………………..(Fill mortality line list)
 Referred
 Other, specify ____________

Version: 19 January 2018

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