CASE REPORT FORM Page 1 of 2

DENGUE (ICD 10 Code: A90-A91) Revision Number: 2020

DOH-EB-PHSD-01 Effectivity:
Region: NATIONAL CAPITAL REGION Municipality/ City: Las Piñas City
Name of DRU: Pamplona Hospital and Medical Center Type: □ RHU □ CHO/ MHO/PHO
Address: 46 Alabang-Zapote Road, Pamplona 1, Las Piñas City □Gov't Hospital □Private Hosital
Name of Interviewer DAN VER TEODORO-GAWARAN,RN,MAN □Clinic

PATIENT"S FULL NAME COMPLETE CURRENT ADDRESS

?
COMPLETE PERMANENT ADDRESS CIVIL DATE ONSET OF

ED
INDIGENOU PLACE OF DATE ADMITTED/

?
Patient No. AGE SEX

ED
DATE OF BIRTH (place of residence within 30 days )

T
LT
STATUS S PEOPLE CONSULTATION SEEN/CONSULTED ILLNESS

IT
Last Name, First Name, Middle Name

SU
DATE OF 1ST

M
N

D
CONSULTATION

A
C
Sex: Specify House or Building number, Specify House or Building number, S-Single M-
Response Codes / Indicate Last Name, followed by First Age: Indicate D Married Sep- Y - Yes Y - Yes
Instructions name, and Middle name - days F - Female MM/DD/YY Street, Barangay, Municipality/City, Street, Barangay, Municipality/City, Separated W- MM/DD/YY NAME OF FACILITY Y - Yes N- No MM/DD/YY MM/DD/YY
M - months Yr. - M - Male Province, Region Province, Region Widowed
N- No N- No
years
 CASE REPORT FORM Page 2 of 2
DENGUE (ICD 10 Code: A90-A91 Revision Number: 2020
DOH-EB-PHSD-01 Effectivity:
Region: NATIONAL CAPITAL REGION Municipality/ City: Las Piñas City
Name of DRU: Pamplona Hospital and Medical Center Type: □ RHU □ CHO/ MHO/PHO
Address: 46 Alabang-Zapote Road, Pamplona 1, Las Piñas City □Gov't Hospital □Private Hosital
Name of Interviewer DAN VER TEODORO-GAWARAN, RN, MAN □Clinic
PATIENT"S FULL NAME NS1 IGg ELISA IGm ELISA PCR
Date Last
Vaccinated Date First
Vaccinated with
Vaccinated with
Patient No. with Dengue Dengue Vaccine Dengue Vaccine Clinical Classification CLASSIFICATION OUTCOME
Last Name, First Name, Middle Name Vaccine (If vaccinated)
(If RESULT Date done RESULT Date done RESULT Date done RESULT Date done
vaccinated)

BILLONES, CALLISTA
2024-000-410 N N/A N/A
ERZA MELGAR

P: P: P: P:
N: No warning signs Positive N: Positive N: Positive N: Positive N:
W: With Negative E: Negative E: Negative E: Negative E: A: Alive
Response Codes / Indicate Last Name, followed by First Y - Yes N- No Equivocal Equivocal Equivocal Equivocal S: Suspect P: Probable C:
Instructions name, and Middle name
MM/DD/YY MM/DD/YY warning signs PR: MM/DD/YY PR: MM/DD/YY PR: MM/DD/YY PR: MM/DD/YY Confirmed D: Died (specify date
S: Severe Pending Result Pending Result Pending Result Pending Result
of death)
Dengue