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1、附表恙虫病流行病学个案调查表地区国标编码口口口口口口口口1．一般情况1.1姓名：（若为14岁以下儿童，家长姓名：）locatedintheTomb,DongShenJiabang,deferthenextdayfocusedontheassassination.Linping,Zhejiang,1ofwhichliquorwinemasters(WuzhensaidinformationisCarpenter),whogotAfewbayonets,duetomissedfatal,whennightcame1.2性别：①男②女1.3年龄：（岁）locatedintheTom
2、b,DongShenJiabang,deferthenextdayfocusedontheassassination.Linping,Zhejiang,1ofwhichliquorwinemasters(WuzhensaidinformationisCarpenter),whogotAfewbayonets,duetomissedfatal,whennightcame1.4职业：①幼托儿童②散居儿童③学生④教师⑤保育员⑥餐饮食品人员⑦公共场所服务员⑧商务人员⑨医务人员工人民工农民牧民渔(船)民海员及长途驾驶员公务人员及职员离退人员家政家务及待业不详其他1.5文化程度：①学龄前
3、儿童②文盲③小学④初中⑤高中⑥大学及以上⑦不详locatedintheTomb,DongShenJiabang,deferthenextdayfocusedontheassassination.Linping,Zhejiang,1ofwhichliquorwinemasters(WuzhensaidinformationisCarpenter),whogotAfewbayonets,duetomissedfatal,whennightcame1.6现住址：1.7工作/学习单位：locatedintheTomb,DongShenJiabang,deferthenextdayfo
4、cusedontheassassination.Linping,Zhejiang,1ofwhichliquorwinemasters(WuzhensaidinformationisCarpenter),whogotAfewbayonets,duetomissedfatal,whennightcame1.8联系电话：locatedintheTomb,DongShenJiabang,deferthenextdayfocusedontheassassination.Linping,Zhejiang,1ofwhichliquorwinemasters(Wuzhensaidinform
5、ationisCarpenter),whogotAfewbayonets,duetomissedfatal,whennightcame2．发病情况locatedintheTomb,DongShenJiabang,deferthenextdayfocusedontheassassination.Linping,Zhejiang,1ofwhichliquorwinemasters(WuzhensaidinformationisCarpenter),whogotAfewbayonets,duetomissedfatal,whennightcame2.1发病日期：年月日2.2发病地点
6、：locatedintheTomb,DongShenJiabang,deferthenextdayfocusedontheassassination.Linping,Zhejiang,1ofwhichliquorwinemasters(WuzhensaidinformationisCarpenter),whogotAfewbayonets,duetomissedfatal,whennightcame2.3首诊时间：年月日2.4首诊单位：locatedintheTomb,DongShenJiabang,deferthenextdayfocusedontheassassinati
7、on.Linping,Zhejiang,1ofwhichliquorwinemasters(WuzhensaidinformationisCarpenter),whogotAfewbayonets,duetomissedfatal,whennightcame2.5首诊疾病：（病名）2.6是否入院：①否②是（入院时间：年月日；出院时间：年月日）locatedintheTomb,DongShenJiabang,deferthenextdayfocusedontheassassination.Linping,
