Acute Encephalitic Syndrome/suspected Je Case Investigation Form And Lab Request Form
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1ACUTE ENCEPHALITIC SYNDROME/SUSPECTED JE CASE INVESTIGATION FORM and LAB REQUEST FORM
EPID Number: AES -____-____-____-____
Reporting information
Hospital:
Date case admitted: ___/___/____
Date Case Reported: ___/___/____
Notified by: __________________
Date Case Investigated: ___/____/____
Investigated by: _______________
Patient information
Patient’s Name: ______________________
Sex: ____
Date of birth: ____/____/______
Age: years ______ months ______
Father’s Name: _______________________
Religion: Buddhist/Hindu/Muslim/other
Address: _________________
Landmark: ______________________
Village: _________________
Phone no: _____________________
District: ________________
Province: ________
Setting: Urban/Rural
Travel history two weeks prior to onset
Dates of travel
Date from:
Date to:
Place of visit
Location
District and Province
Is this JE/Dengue endemic area? Yes/No
Immunization history
Most recent vaccine taken: (specify type)
Date: ___/____/____ Dose Number: 1/2/3/4/5/B
Other vaccines given earlier
Date: ____/____/____Dose Number: 1/2/3/4/5/B
Date: ____/____/____Dose Number: 1/2/3/4/5/B
Date: ____/____/____Dose Number: 1/2/3/4/5/B
Signs and Symptoms
Date of onset of first symptom: ____/____/_____
Fever: Yes/No/Unknown
Change in mental status: Yes/No/Unknown
Seizure:
Yes/No/Unknown
Paralysis: Yes/No/Unknown
Headache: Yes/No/Unknown
Neck rigidity: Yes/No/Unknown
Unconsiousness: Yes/No/Unknown
Any other, specify: _______________________________________________________________________________
Sample collection and shipment (Coordinated by District)
Date
Date sent to lab
Name of Laboratory
Serum 1
Serum 2
CSF
For use by the receiving Laboratory
Name of laboratory:
Name of person receiving the specimen:
Date
Processed?
Test
Condition
Laboratory result
Date result sent to pragrame
received
Y/N
performed
Serum 1
Serum 2
CSF
Remarks
Discharge status and Final Classification (By District)
Status of discharge: Alive/Dead/Unknown
Date of discharge: ___/___/____
If alive, status if recovery:
Recovered completely/Recovered with disability
If died, date of death: _____/______/______
Final classification:Laboratory confirmed____/Probable____/AES unknown/AES other agent (specify_____)
Clinical diagnosis: ________________________________
(Name & Signature)
Designation
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