Pertussis

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:	EPI ID:	Patient's Last Name First Name: Middle Name:

Current Address: Permanent Address:	Sex: Male Female Pregnant? Yes No Unknown If Yes, weeks of pregnancy	Date of Birth:	Age: Days Months Years

Occupation:

Phone:

Civil Status:

Patient Admitted?:

Yes

Unknown

Date Admitted/Seen/Consult:

Suspect Case: Any person with cough lasting at least 2 weekswith at least one of the following:

Paroxysms (i.e. fits) of coughing
Inspiratory “whooping”
Post-tussive vomiting (i.e. vomiting immediately after coughing) without other apparent cause
Apnea, with or without cyanosis (For infants < 1 year old)

Confirmed Case:

A suspect case that is laboratory confirmed or epidemiologically linked to a laboratory-confirmed case
Laboratory criteria for diagnosis: Isolation of Bordetella pertussis from clinical specimen

Attach File

Patient ID	Patient Name	Gender	Blood Group	Age

Name of Parent / Caregiver:		Contact Nos.:
Date of Report:	Name of Reporter:	Contact Nos.:
Date of Investigation:	Name of Investigators:	Contact Nos.:
II. BACKGROUND INFORMATION
Pertussis-containing vaccine doses: Yes No If Yes, Number of total doses: Zero 1 2 3 Unknown Date of last vaccination Source of Information Call Recall TCL Known Exposure to Confirmed case Probable case Probable case International traveler Other means of exposure School name, if applicable: Any travel within 14 days before onset of illness Yes No If yes, where (in detail)
III. CLINICAL DETAILS
Check Signs/ Symptoms which apply: Date onset of fever and or sore throat (MM/DD/YYYY): Post-tussive vomiting Apnea (for infants) Paroxysms of coughing Inspiratory whooping Coughing lasting at least 2 weeks Others, specify Outcome at discharge Clinically well Death (Date Died) Referred to: Other, specify
IV. TREATMENT INFORMATION
Administered antibiotic therepy? Yes No Unknown If Yes, Date
V. SPECIMEN COLLECTION for Bordetella Pertussis
Sample collected: Yes No If Yes, type sample: throat swab nasal swab Date of collection: Date of sample send:
Date of results: Check what applies: Positive Negative Undetermined Not Processed
VI. FINAL CLASSIFICATION: Suspect Confirmed
To include linelist for close contacts