Acute Flaccid Paralysis

Name of DRU:

Address:

Type:

RHU

CHO

Gov't Hospital

Private Hospital

Clinic

Gov't Laboratory

Private Laboratory

Airport/Seaport

I. PATIENT INFORMATION
Patient Number:	Patient's Last Name First Name: Middle Name:
Sex: Male Female Date of Birth: Age: Days Months Years

Name of Parent / Caregiver: Contact Nos.:	Current Address: Permanent Address:
Patient Admitted?: Yes No	Date Admitted/Seen/Consult:
Date of Report:	Date of Investigation:
Name of Investigators:	Contact No.:
In the case a member of an Indigenous Group? Yes No If YES, Specify:

An AFP case is defined as a child less than 15 years of age presenting with recent or sudden onset of floppy paralysis or muscle weakness due to any cause , OR
Any person of any age with paralytic illness if poliomyelitis is suspected by a clinician

A. Sensory status is presented in percentage and categorized as follows:

B. Deep tendon reflexes are presented in (+) symbol and categorized as follows:

C. Motor Status is presented in fraction and categorized as follows

0/5 = absent or no movement
1/5 to 3/5 = reduced movement (with movement but not against resistance or gravity)
4/5 to 5/5 = normal (movement with full resistance and against gravity)

II. CLINICAL DATA (Put a check [✓] in the appropriate box)
Previous Consultation	PRODROME	PARALYSIS	STATE OF FLACCID PARALYSIS	Sensory Status	Deep Tendon Reflexes	Motor Status
Name and Address of health facility 1: Date of visit: Name and Address of health facility 1: Date of visit:	Fever: Y N Cough: Y N Diarrhea/Vomiting: Y N Muscle pain: Y N Meningeal sign: Y N	Date onset: Present at birth? Y N Asymmetric? Y N PROGRESSION Paralysis fully developed within 3 to 15 months from onset of illiness? Y N Direction of paralysis: Ascending Descending	Right Arm: Y N Left Arm: Y N Right Leg: Y N Left Leg: Y N Breathing muscles: Y N Neck muscles: Y N Facial muscles: Y N Working Diagnosis:
				NOTE: Instructions on the grading/scoring of the sensory status, deep tendon reflexes an motor status are presented at the back of this page

III. EPIDEMOLOGIC DATA
History of neurological disorder?: Yes No If YES, Specify: Did the patient travel (>10 km from house) one month prior to illness?: Yes No If YES, Specify place: Date traveled From To: Other AFP cases in patient's community within 60 days of patient's paralysis? Yes No Does the patient had any history of injection, trauma and/or animal bite? Yes No If YES, Specify: ls there an Environmental Sample tested positive for WPV/ VDPV/Sabin-like 2 in the area? Yes No If YES, Specify the date:
IV. IMMUNIZATION HISTORY
Polio Vaccine given: Yes No Is this a "Hot case"? Yes No Total Routine OPV doses received: Date last OPV dose: Total SIA OPV doses received: Date last SIA OPV dose: Total IPV doses received: Date last IPV dose:

V. LABORATORY DATA
Stool sample #	Collected?	If YES, date taken?	Date sent to RITM	Date received RITM	Result		Amount of Stool (To be filled out by RITM)	Specimen Condition (To be filled out by RITM)
1	Yes No				WPV Sabin-like VDPV NEG NPEV	If WPV, Sabil-like or VDPV: Specify: Type 1 Type2 Type 3		No. of ice packs Qty. of icepacks: Frozen Thawed but cold Warm Type of Container: Name of Courier: Received By:
2	Yes No				WPV Sabin-like VDPV NEG NPEV	If WPV, Sabil-like or VDPV: Specify: Type 1 Type2 Type 3		No. of ice packs Qty. of icepacks: Frozen Thawed but cold Warm Type of Container: Name of Courier: Received By:

VII. CLASSIFICATION (TO BE FILLED UP BY THE EXPERT PANEL ONLY)
Final Classicifation	Classification Criteria	Final Diagnosis
Confirmed with polio Vaccine-derived paralytic polio (VDAPV) Vaccine-associated paralytic polio (VAPP) Recipient VAPP Contact VAPP Polio compatible Discarded as Non-Polio Date classified:	Laboratory Lost to follow-up Death With residual paralysis Without residual paralysis	Was this case considered as NOT AFP? Yes No

VI. 60-DAY FOLLOW-UP
Expected date of follow up: Follow-up done Yes No If YES, actual date of follow-up conducted: P.E. done? Yes No Residual paralysis at 60 days?: Yes No If Yes, Specify: Flaccid/Floppy Spastic Presence of Atrophy? Yes No Site: RA Yes No LA Yes No RL Yes No LL Yes No	If No, reason for P.E.: Patient Died Date: Lost to Follow-up Others, Specify Note other observations: