Name of DRU:
Type: RHU CHO Gov’t Hospital Private Hospital Clinic
Address: Gov’t Laboratory Private Laboratory Airport/Seaport
I. PATIENT Patient Number: Patient’s First Name Middle Name Last Name
INFORMATION:
Sex: Male Female Date of Birth: ____/____/____ Age: ____ Days Months Years
MM DD YY
Complete Address: District: ILHZ:
MM DD YY
Patient Admitted? Yes No Date Admitted/ Seen/Consult:
MM DD YY MM DD YY
Date of Report: Date of Investigation:
Total OPV/IPV doses received: ________ Date last dose of OPV/IPV: ___/___/___ Is this a “Hot case”? Y N
V. LABORATORY DATA
Stool Amount of
If YES, date Date sent to Date received Stool Specimen Condition
sample Collected? Result
taken RITM RITM (To be filled out by (To be filled out by RITM)
# RITM)
≤ 25% = Absent
≥ 25% but <100% = Reduced
100% = Normal
B. Deep tendon reflexes (DTRs) are presented in (+) symbol and categorized as follows:
none or 0 = absent
+ = reduced
++ = normal
+++ with/without clonus = increased or exaggerated