A. IDENTITAS PENDERITA/SUSPEK
1. Nama penderita : ..........................................Umur : .......... Bulan/Tahun* L / P*
2. Alamat :.....................................................................................................................
Desa/Kelurahan* :...........................................................................RT=............. RW=............
Kab/Kota* : .....................................................................................................................
3. Alamat pekerjaan / sekolah :..........................................................................................................
..........................................................................................................
4. Hubungan dengan penderita :(Diisi bila respoden orang-orang kontak)
a. Hubungan sedarah serumah (orang tua, anak, saudara, bukan saudara)
b. Hubungan tidak serumah (tetangga, temankantor, teman sekolah, saudara*, lainnya,
sebutkan, ……….)
B. RIWAYAT PENYAKIT
1. Apa gejala yang timbul pertamakali ? sebutkan, .........................................................................
2. Kapan atau jam berapa mulai gejala pertama kali tersebut mulai timbul ?
………………………
3. Setelah timbul gejala tersebut tadi, apa yang dilakukan ? sebutkan,
a. ....................................................................................................................................................
b. ....................................................................................................................................................
c. ....................................................................................................................................................
d. ....................................................................................................................................................
e. ....................................................................................................................................................
4. Gejalaselain yang timbul
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