MacauPolioModelo1

Integrated Program for the
Eradication of Poliomyelitis in Macau

Acute Flaccid Paralysis (AFP) Notification Form

Reference: SSM-UTVE-MOD.100, Modelo 1

Mod.1 FORM FOR THE REPORTING OF NOTIFIABLE DISEASES	TO BE FILLED OUT BY THE SANITARY AUTHORITY
	Date: __ __ __ __-__ __-__ __	_____________
	(year-month-day)	(signature)
	CID.9:
	Year:
	Case No:

TO BE FILLED OUT BY THE REPORTING PHYSICIAN, IN CAPITALS

PATIENT
	Registry No:
Name (roman characters):
Name (chinese characters):	Sex:	Date of birth:
Address:
Country of birth:	Occupation:

DISEASE
Disease: AFP or acute poliomyelitis				Date of onset of symptoms:
Clinically confirmed:	Confirmed by lab:				Waiting for confirmation:
Hospitalization (yes/no):		Name of hospital:
More cases at home:			How many:			Death of patient:
More cases in other place:			How many:			Where:

PHYSICIAN
Name (roman characters):
Name (chinese characters):	Tel.:		SSM license No:
Address:
Notification date:		Signature:
Remarks:
« Patient pager, phone and fax numbers, and other possible contacts, shall be written in this space »

© Serviços de Saúde de Macau, 1999