人感染豬流感個(gè)案調(diào)查表

1、人感染豬流感個(gè)案調(diào)查表我們來(lái)自疾病預(yù)防控制中心（CDC），請(qǐng)您按實(shí)際情況填寫(xiě)以下內(nèi)容，謝謝合作Questionnaire for swine flu infected case We are from Center for Disease Prevention and Control（CDC）, please fill in the form according to your true situation, thanks for your cooperation.問(wèn)卷編碼 Questionnaire No. 一、 病例的發(fā)現(xiàn)/報(bào)告情況. Case finding/reporting info

2、rmation 1.病例的首次發(fā)現(xiàn)單位(具體到科室)：_1. The name of institution firstly finding infected patient (be specific to hospital department) ：_1.1聯(lián)系方式: (1)電話:_ (2)傳真: _ (3)E-mail: _1.1 Contact： (1) Tel:_ (2) Fax No._(3) E-mail: _1.2發(fā)現(xiàn)時(shí)間: 年月日時(shí)1.2 Finding date: yymmddhh2.首次報(bào)告單位:2. The first reporting institution:2.1接

3、到報(bào)告單位:2.1 Institution receiving the report2.2報(bào)告方式: 電話 傳真 E-mail 其它2.2 Reporting ways: Tel Fax E-mail Others 2.3報(bào)告時(shí)間: 年月日時(shí)2.3 Reporting date: yymmddhh2.4報(bào)告疾病名稱: 2.4 Name of disease reported :二、 病例一般情況 General information1.病例姓名： 家長(zhǎng)姓名(若14周歲，請(qǐng)?zhí)顚?xiě)):1.Name: Parents name(cases under 14 years old, please wri

4、te down here):2.性別： 男 女2.Sex: Male Female3.國(guó)籍：3. Nationality:4.民族：漢族 其它,_4. Ethnic: Han Others,_5.出生日期： 年月日(如出生日期不詳，則實(shí)足年齡：歲或月)5. Date of birth: yymmdd(if birth date is uncertain , please write patients age here: Year-old or month-old)6.現(xiàn)住址： 省 市 縣(區(qū)) 鄉(xiāng)(街道) 村(棟) 組(單元) 號(hào)6. Address: _ Province _City _Co

5、unty (district) _ Township (street) _Village (building) _Team( unit) NO. _ 7.學(xué)習(xí)或工作單位：7.Current study or work place:8.聯(lián)系電話:(1)手機(jī): (2)家庭電話: (3)其它聯(lián)系人電話:8.Phone No.: (1)Cell phone No.: (2)Home phone No.: (3) Phone No of other relevant person: 9.職業(yè)： 幼托兒童 散居兒童 學(xué)生 教師 保育保姆餐飲業(yè) 商業(yè)服務(wù) 工人 民工 農(nóng)民牧民 漁(船)民 干部職員 離退人員

6、 家務(wù)待業(yè) 醫(yī)療機(jī)構(gòu)工作人員 其他9.Professions: Children in the kindergarten Children not in the kindergartenStudent Teacher Baby-sitter Employee in the catering industry Business service Industry blue collar Migrant worker Farmer Herdsman Fisherman Cadre Retiree House husband/wife Unemployed Health-care worker Oth

7、ers 三、 病例的發(fā)病與就診經(jīng)過(guò) 、Information of disease development and corresponding diagnose and treatment1.發(fā)病日期：年月日 1. Date of onset of symptoms: yymmdd2.首診醫(yī)療機(jī)構(gòu)名稱(具體到科室):_2. First medical institution attended (be specific to department) :_3.前往醫(yī)療機(jī)構(gòu)就診前，是否自行服藥： 是 否 不知道3. Self-medication before visiting medical in

8、stitutions? Yes No Unclear3.1若自行服藥，則服藥名稱:_3.1 If yes , which:_四、病例的臨床表現(xiàn) .clinical manifestation1.臨床表現(xiàn)(可多選):1. Symptoms（more than one choice are available）:發(fā)熱：體溫(最高) _ 持續(xù)時(shí)間:_天 寒戰(zhàn)Fever: Body temperature(highest) _ Lasting _ days Sensation of chill咳嗽 咳痰 咽痛 頭痛 鼻塞 流涕 Cough Phlegm Sore throat Headache Nas

9、al congestion Runny Nose 肌肉酸痛 關(guān)節(jié)酸痛 乏力 胸悶 氣促 Muscle aches Joint aches Fatigue Chest Stuffiness Shortness of breath呼吸困難 腹瀉 結(jié)膜炎 Scant of breath Diarrhea Conjunctivitis其它臨床表現(xiàn):_Other _2.是否服用“達(dá)菲” 是 否 不知道2. Use of “Tamiflu” ? Yes No Unclear2.1如果回答“是”，請(qǐng)?zhí)顚?xiě)詳細(xì)服藥情況，包括服藥起止日期、服用劑量、是否有副作用等:_2.1 If yes, please writ

10、e down the details including the starting and ending date of medication, dose, side effects etc. :_五、病例生活習(xí)慣、既往健康史. Living habits and past medical history1.飯前洗手: 每次均洗手 偶爾洗手 從不洗手 其它1. How often did you wash hands before meals: Every time Occasionally Never Others 2.是否抽煙：是 否2. Smoke? Yes No 3.1若抽煙，每天幾支

11、：14支 59支 1020支 20支以上3.1 If yes, how many cigarettes each day: 1-4 5-9 10-20 Above 204.是否有慢性疾病，若有(醫(yī)生已經(jīng)診斷,可多選)4. Did you have any chronic diseases? (Diagnosed , more than one choice are available)哮喘 慢性支氣管炎 其它慢性肺部疾病 冠心病糖尿病 腎病 免疫缺陷 其它慢性疾病:_Asthma Chronic bronchitis Other chronic lung disease Coronary he

12、art disease Diabetes mellitus Kidney disease Immunodeficiency Other chronic diseases:_5.是否懷孕： 是,孕期_月 否5. Pregnant? Yes, _month(s) No6.一年內(nèi)是否接種流感疫苗： 是 否6. Seasonal influenza vaccination last year? Yes No 六、病例發(fā)病前的暴露情況. Exposure history prior to onset of symptoms1.發(fā)病前7天內(nèi)是否接觸有“感冒”癥狀的病人： 是 否 不知道1. In the

13、7 days prior to onset of symptoms, did you contact with patients having “common cold” :Yes No Unclear1.1接觸方式主要是（可多選）： 近距離（間隔<2米）相處，但沒(méi)有說(shuō)話; 近距離（間隔<2米）面對(duì)面說(shuō)話; 直接接觸（有身體皮膚的接觸） 接觸患者分泌物; 接觸患者碰觸過(guò)的物體，如門把手，毛巾，桌子等; 吃過(guò)患者烹飪的食物1.1 Contacting ways (multiple choice) :Short-distance(<2m) contact, without tal

14、king Short-distance(<2m) face to face talking Direct contact (contact with the skin of patients) Touched the patients secretions Contacted with the objects touched by the patient before, such as door handles, towel, table, etc. Ate the food cooked by the patients1.2接觸患者時(shí)是否采取防護(hù)措施及其它預(yù)防措施:帶手套 穿防護(hù)服 帶

15、口罩 服用抗病毒藥物 無(wú)任何防護(hù)措施1.2 Which protective measures did you take when contacting the patient?Wearing gloves Wearing protective clothing（gown） Wearing a mask Taking antiviral medicine None1.3接觸者是否被確診為豬流感病例: 是 否 不知道1.3 Were contacts diagnosed as influenza A (H1N1, swine flu)（: Yes No Unclear2.發(fā)病前7天內(nèi)，是否到過(guò)豬

16、流感病毒學(xué)實(shí)驗(yàn)室: 是 否2. Had you ever been to swine flu virological laboratory in the 7 days prior to onset of symptom?Yes No2.1若曾到過(guò)實(shí)驗(yàn)室，是否進(jìn)行防護(hù)： 是 否2.1 If yes, did you wear any personal protective equipment? Yes No3 發(fā)病前7天是否到過(guò)以下場(chǎng)所：（可多選）幼托機(jī)構(gòu) 學(xué)校 醫(yī)療機(jī)構(gòu) 電影院 商場(chǎng)或超市 其它公共場(chǎng)所:_3 Had you ever been to the following places

17、in the 7 days prior to the onset symptoms: (the choice could be more than one) Kindergarten School Health care facility Cinema Shopping Mall or Supermarket Other public places: _ 4.發(fā)病前7天是否外出旅行: 是 否 不知道4. Did you travel 7 days prior to the onset: Yes No Unclear4.1如果是，請(qǐng)說(shuō)明_4.1 If yes, please write the

18、details_4.2 當(dāng)?shù)厥欠裼腥烁腥矩i流感A(H1N1)疫情: 是 否 不知道4.2 Were there any confirmed influenza A (H1N1) cases in the place you travelled to? Yes No Unclear5.發(fā)病前七天曾經(jīng)搭乘過(guò)的交通工具：私家車 出租車 公交車 長(zhǎng)途客車渡輪/輪船 飛機(jī)，航班號(hào)_ 火車,列次_ 其它_5.Which vehicles did you take in the 7 days prior to the onset: Private car Taxi Bus Long-distance bus

19、 Ferry/ship Airplane , Flight NO._ Train NO. _ Other_注：如果有豬相關(guān)接觸史，請(qǐng)?zhí)罡奖?人感染豬流感個(gè)案調(diào)查表（曾有豬接觸史）Note: If you had ever contacted with pig in the 7 days prior to the onset of symptoms, please fill in Appendix 2- Influenza A (H1N1) infected person investigation table (had exposure to pigs)七、 轉(zhuǎn)歸與最終診斷情況.Outcome

20、 and the final diagnosis 1.病例最終診斷：確診病例 疑似病例 排除(病名: )1. Final diagnosis: Confirmed cases Suspected cases Excluded (Disease: ) 2.診斷單位:2. Diagnostic unit:3.轉(zhuǎn)歸: 痊愈 死亡 其他3. Outcome: Recovered Died Others八、 調(diào)查小結(jié).Investigation Summary調(diào)查單位： 調(diào)查時(shí)間：月日-月日Investigation units: Investigation period: month day - mo

21、nth day 調(diào)查者簽名：Investigators Signature:附表2 人感染豬流感個(gè)案調(diào)查表（曾有豬接觸史）Appendix 2 Questionnaire for swine flu cases (the history of exposure to pigs)一、 病例發(fā)病前的暴露情況. Exposure history prior to the onset of symptoms您已回答曾經(jīng)在發(fā)病前接觸過(guò)豬，請(qǐng)問(wèn)：Once you had ever exposed to the pigs prior to the onset of illness, please answe

22、r the following questions1.與豬的接觸方式: 飼養(yǎng) 打掃、清洗豬舍 接觸動(dòng)物分泌物 購(gòu)買加工生鮮豬肉職業(yè)運(yùn)輸 收集或運(yùn)輸豬類糞便 買賣活豬 宰殺豬類 處理/掩埋豬類1. Contacting Patterns:Raising Cleaning pig cage Contact with animal secretions Buy/cook fresh pork Transportation Collect or transport swine excretion Buy/sell live pigs Slaughter Handle / embed pigs2 累計(jì)接

23、觸時(shí)間:_分鐘2. Cumulative contact time: _minutes3.接觸豬后是否洗手： 每次均洗 偶爾洗一次 從不洗手3. Have you washed your hands after contacting with pigs: Every time Occasionally Never 4.是否在病前7天內(nèi)到過(guò)： 飼養(yǎng)場(chǎng) 農(nóng)貿(mào)市場(chǎng) 動(dòng)物園 其它4. Within 7 Days prior to the onset, have you ever been to: Farms Farmers market Zoo Others5.病前7天內(nèi)是否接觸病死豬： 是 否 不知

24、道5.Have you ever contacted dead pigs 7 days prior to the onset: Yes No Unclear5.1若接觸，則接觸方式: 宰殺、加工病死動(dòng)物 接觸病死豬排泄物接觸病死豬分泌物 直接接觸病死豬 食用病死豬肉 其它5.1 If yes, which way? Slaughtered/processed dead animal Contacted with excretion of dead pig Contacted with secretions of dead pig Contacted with dead pig directly

25、 Ate meat of dead pig Others5.2 接觸時(shí)間:_分鐘5.2 How long did you contact: _minute5.3 若食用病死豬肉，則所食用時(shí)是否熟透: 是 否 不知道5.3 If you have eaten pork of dead pig, were they well-cooked: Yes No Unclear6.處理病死豬類時(shí)是否采取防護(hù)措施及其它預(yù)防措施:帶手套 穿防護(hù)鞋 帶口罩 服用抗病毒藥物 無(wú)任何防護(hù)措施6.Which protection measures did you take when you processed the

26、 dead pigWear gloves Wear protective shoes Wear masks Take antiviral drugs Without any protective measures 7.處理病死豬后是否洗手：每次均洗 偶爾洗一次 從不洗手 其它7.How often did you wash your hands after dealing with dead pig: Every time Occasionally Never Other二、病例居住環(huán)境及暴露情況、Living environment and exposure of cases1.病例居住地點(diǎn)

27、(村莊/居民區(qū))豬病死情況: 有 無(wú)1. Sick or dead pig situation in your living place (village / residential area): Yes No 2.農(nóng)業(yè)部門是否已經(jīng)證實(shí)死亡家豬死于H1N1型豬流感:是 否 證實(shí)中 不知道2. Has the agricultural sector confirmed that the pigs died of H1N1 swine flu? Yes No Ongoing Unclear3.當(dāng)?shù)丨h(huán)境是否已經(jīng)進(jìn)行徹底消毒: 是 否 不知道3.Whether the local place has been thoroughly disinfected: Yes No Unclear3.1 若已經(jīng)徹底消毒,則時(shí)間為: 年月日3.1