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Epidemic Reporting Format
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* Indicates required question
Name of Reporting Unit
*
Your answer
Address of Reporting Unit
*
Your answer
Name of Reporting Person
*
Your answer
Contact Number of Reporting Person
*
Your answer
Patient's Name
*
Your answer
Patient's Age
*
Your answer
Patient's Gender
*
Choose
Female
Male
Other
Patient's Address
*
Your answer
Patient's Mobile Number
*
Your answer
Diagnosis
*
Your answer
Date of Admission
*
MM
/
DD
/
YYYY
Date of Discharge if applicable
MM
/
DD
/
YYYY
Confirmatory Laboratory test done
*
Your answer
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