填表说明：
1、此表用于学校等集体单位内聚集性上感高热暴发疫情现场流行病学调查处理。
2、表中是否就诊、流感疫苗接种史、接触史、症状栏用1或0填写（肯定回答，填1；否定回答，填0）
3、表中日期栏用标准日期形式填写，如：3月2日；体温栏填写患者最近一次测量的体温值。
4、实验室快速检测结果、患者并发症、是否采样等情况填入备注栏中。
调查单位 调查人 调查时间
附表9
上海市 （单位）流感样病例采样登记表
编
号
| 患者
姓名
| 性别
| 年龄
| 职业
| 现住址及联系电话
| 发病日期
| 主要临床表现
| 用药情况
| 采样检测情况
|
体
温
（℃）
| 咳
嗽
| 咽
痛
| 全身酸痛
| 其
它
| 抗生素
| 抗病毒药
| 退烧药
| 中成药
| 达菲
| 采样日期
| 咽拭子
| 鼻拭子
| 结果
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
