登革热调查报告.doc

登革热调查报告附表1登革热个案调查表县名称:国标码:□□□□□□病例编号:□□□□□一、::1男,2女□:_____岁□□□:1汉族,2壮族,3维吾尔族,4其他少数民族□:□:___________________________________;联系电话::___省___县___乡___村二、:_______年______月_______日□□□□/□□/□□:_______年______月_______日□□□□/□□/□□:::_____________________□□□□□□:_______年______月_______日□□□□/□□/□□:_______年______月_______日□□□□/□□/□□:□1登革热疑似病例,2临床诊断病例,3实验室确诊病例,4其他9、临床诊断日期:_______年______月_______日□□□□/□□/□□:□1登革热疑似病例,2临床诊断病例,3实验室确诊病例,:1典型,2轻型,3重型,4其他□:1痊愈,2好转,3死亡□三、:1是,0否□:1有,0无□:1有,0无□如有,则热型为:1双峰热,2稽留热,3驰张热,4其他□:1有,0无□:1有,0无□:1有,0无□:1有,0无□:1有,2无□:1有,0无□:1有,2无□:1有,2无□:1有,2无□:1有,2无□:1有,2无□:1有,2无□:1有,2无□:1有,2无□:1有,2无□:1有,2无□如有,则出血点为:1散在,2条/线状,3簇状,4其它_________□:1有,2无□如有,则皮疹为:1斑丘疹、,2麻疹样皮疹条/线状,3猩红热样皮疹簇状,4红斑疹,5其它_________□皮疹部位:1全身,2四肢,3躯干,4面部□:1有,2无□:1有,2无□:1有,2无□:1有,2无□:1有,2无□:1有,2无□:1阳性,2阴性,3未做此项检查,4不详□:1正常,2增多,3减少,4未做此项检查□:□:□:1有,2无,3未做此项检查□:□:1正常,2延长,3缩短,4未做此项检查,5不详□□:1正常,2异常,3未做此项检查□:1正常,2异常,3未做此项检查□:1正常,2异常,3未做此项检查□五、:1正常,2