TRANSHEALTHCARE-MONITORING OF HUMAN INFLUENZA VIRUS
CASE RECORD FORM
Patient Name:
Age:
Address:
Sex:
Male
Female
Date of Illness onset:
Date of Fever Onset
Post illness Day
Details of pets(if any):
1.HISTORY OF ILLNESS
SYMPTOMS
YES/NO
DURATION
COMMENT
Sudden onset of symptoms<12hrs
yes
no
fever
yes
no
Chills and Rigor
yes
no
Nasal Discharge
yes
no
cough
yes
no
Breathlessness
yes
no
Headache
yes
no
Bodyache
yes
no
Concomitant Illness
yes
no
Vomiting
yes
no
Seizure
yes
no
Recent visit outside India
yes
no
Expectoration
yes
no
Influenza Immunization
yes
no