Philippine Integrated Disease Case Report Form

Surveillance and Response

Non-neonatal Tetanus (ICD 10 Code: A35)
Region: ____________________________ Province: ___________________________ Municipality/City: ________________________________________
Name of DRU: _________________________________________________________________ Type: ⃞RHU ⃞CHO ⃞Gov’t Hospital ⃞Private Hospital ⃞Clinic
Address: ______________________________________________________ ⃞Private Laboratory ⃞Public Laboratory ⃞Seaport/Airport

Date
Patient No. Patient’s Full Name Age Sex Occupation Complete Address
of Birth

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Age: Indicate
D - days
Response
Indicate First name, Middle name, Last M - months Indicate
Codes / mm/dd/yy Specify Street/Purok/Subdivision, House #, Barangay, Municipality/City, Province
name Yr. - years occupation
Instructions
Sex:F - Female
M - Male

Case Definition:

 Suspected Case: Not applicable

 Probable Case: Not applicable

 Confirmed Case: Acute onset of hypertonia and/or painful muscular contractions (usually muscles of the neck and jaw) and generalized muscle spasms without apparent medical
cause as reported by a health care professional.
 Philippine Integrated Disease Case Report Form
Surveillance and Response
Non-neonatal Tetanus (ICD 10 Code: A35)

Received Received
Date Admit- Date
Admit- With recent tetanus tetanus Out-
Patient’s Full Name ted/seen/ of Onset of Wound site Wound type Skin lesions
ted? wound? toxoid vac- antitoxin or come
consulted Illness
cination? TIG?

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 Abrasion
Y = Yes  Animal bite Y - Yes (specify)
 Avulsion N - No
N = No  Burn U - Unknown
U = Unknown  Open fracture
Head & Neck A - Alive
Trunk  Crash NOTE: Skin lesions D - Died
NOTE:  Dental (caries/ Y - Yes Y - Yes
Y - Yes Upper extremity for the past 3 (specify
Response Codes / Instructions mm/dd/yy mm/dd/yy Recent extraction) N - No N - No
N- No Lower extremity  Fireworks months, which date)
wound refers U - Unknown U - Unknown
Unknown  Insect bite may include : ab- U - Un-
to past 3
 Laceration scess, ulcer, blis- known
months
whether  Puncture ter, gangrene, cel-
 Surgery lulitis, etc.
healed or not  Tissue necrosis
 Others, specify