QuestionnaireofIndividualCaseofHumanAvianInfluenza.docVIP

PAGE  PAGE 5 Questionnaire of Individual Case of Human Avian Influenza Type of Disease: (1) Confirmed (2) Suspected National Standard Code □□□□□□ Case Code □□□□ ? 1. General Information Name: ________________ (Parent’s Name: ) Telephone I.D. Number: □□□□□□□□□□□□□□□□□□ Sex: (1) Male (2) Female Age (year): _______ Occupation: (1) Preschooler (2) Unschooled child (3) Student (4) Teacher (5) Babysitter/maid (6) Restaurant worker (7) Service worker (8) Factory worker (9) Peasant worker (10) Farmer (11) Animal farm worker (12) Fisherman (13) Government worker (14) Retiree (15) House worker/unemployed (16) Other 1.7 Affiliation: ______________________________________________ 1.8 Current Address: ________ Province ________ City _________ County (District) _______ Town (Street) ________ Village 1.9 Address of Registered Permanent Residence: ________ Province ________ City _________ County (District) _______ Town (Street) ________ Village 1.10 Pre-Existing Diseases (Pulmonary Disease, Diabetes, Hypertension, Heart Diseases, Renal Diseases, et. al): (1) Yes, Name of Disease: (2) No (3) Unknown 1.11 History of Influenza Vaccination: (1) Yes (2) No (3) Unknown If yes, the date of last vaccination: yy mm dd 2. Onset and Medical Examination 2.1 Date of Onset: yy mm dd 2.2 Onset Place: __________ Province ____________ City _____________ County (District) 2.3 Medical Examination (from Onset to Hospitalization) DateHospital DepartmentDiagnosisHospitalized? 2.4 Date of Hospitalization: yy mm dd 2.5 Name of the Hospital: _____________________________________ 2.6 Inpatient Number: □□□□□□□□ 2.7 Diagnosis: (1) Confirmed Avian Influenza (2) Suspected Avian Influenza (3) Other _______________ □ 2.8 Date of Reporting: