ANEXO 2 E T A V -2
E S T U D IO D E E V E N T O S T E M P O R A L M E N T E A S O C IA D O S A V A C U N A C IÓ N (E T A V ) F O R M A T O I N T E R I N S T I T U C IO N A L D E
E S T U D IO Y S E G U IM IE N T O
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N o m b r e d e l p a c ie n te :
E s c o la r id a d :
N o m b re (s )
1 . A n a lf a b e t a 2 . P r im a r ia in c o m p le t a 3 . P r im a r ia c o m p le t a 4 . S e c u n d a r ia ó T é c n ic a 5 . B a c h ille r a t o 6 . L ic e n c ia t u r a 7 . O t r a _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
________________________ ________________________ A p e llid o p a t e r n o A p e llid o m a t e r n o E s c o la r id a d : ( V e r c o d ig o d e a r r ib a )
N o m b r e d e la m a d r e o tu to r : Edad:
_________________________________
A p e llid o m a t e r n o
A p e llid o p a t e r n o Edad:
F O L IO E T A V : _ _ _ _ _ _ _ _ _ _
________________________
A t e n d id o p o r m é d ic o d e :
_________________________________ N o m b re (s )
1. SSA
2 . IM S S -O B 3 . IS S S T E 4 . O tra s 5 . IM S S -O P 6 . D IF 7 . P E M E X 9 . S E C M A R 1 0 . P r iv a d a ¿ C u á l? : _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 . R e c u p e r a d o s in s e c u e la 2 . - R e c u p e r a d o c o n s e c u e la s 3 . D e f u n c ió n 4 . H o s p it a liz a d o 9 9 . S e ig n o r a 1 . (< 1 h ) 2 . (1 -1 2 h ) 3 . (1 3 -2 4 h ) 4 . (2 5 -4 8 h ) 5 . E n c u r s o 9 9 . S e ig n o r a
E v o lu c ió n a l m o m e n t o d e la n o t if ic a c ió n : D u r a c ió n d e l e v e n t o : C la s if ic a c ió n in ic ia l:
1. Leve
2 . M o d e ra d o
3 . G r a v e 9 9 . S e ig n o r a
C U A D R O C L ÍN IC O / D IA G N Ó S T I C O S I n ic io d e p r im e r s ig n o ó s ín t o m a : I n t e r v a lo e n t r e la v a c u n a c ió n y e l p r im e r s ig n o ó s ín t o m a :
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D ía
M es
Año
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D ía s
M in . In s t r u c c i o n e s : S e ñ a la r d e a c u e r d o a la r e s p u e s t a c o n
1 = S i,
2= No
y
: H r.
M in .
9 9 = S e ig n o ra D IA G N Ó S T IC O S
S IG N O S Y S ÍN T O M A S F ie b r e :
S i s t e m a N e u r o ló g i c o
Tem pe ___ ___ : ___ C '
E n c e f a lit is
F e c h a d _ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _ _ _
C r is is c o n v u ls iv a s
D u r a c ió n :
M e n in g it is
T ie m p o e n t r e la a p lic a c ió n d e la v a c u n a e in ic io d e f ie b r e :
N e u r it is b r a q u ia l
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
E p is o d io h ip o t ó n ic o c o n h ip o r r e s p u e s t a > 4 8 h
D ía s : _ _ _ _ _ _ _
L la n to p e r s is te n te :
d e s p u é s d e la in m u n iz a c ió n
F e c h a d e in ic io :
H ip e r t e n s ió n in t r a c r a n e a n a
D u r a c ió n :
_ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
D ía s : _ _ _ _ _ _ _
F e c h a d e in ic io : D u r a c ió n :
_ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
N e u r it is ó n e u r a lg ia . D ía s : _ _ _ _ _ _ _
D o lo r , in f la m a c ió n y c a lo r lo c a l
S ín d r o m e d e G u illa n B a r r é P a r á lis is f lá c id a a g u d a
I n d u r a c ió n A bsceso O tra E x a n te m a
P a r á lis is d e B e ll D is m in u c ió n d e la a u d ic ió n
R e a c c ió n lo c a l:
O tro : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
¿ C u á l?
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S i s t e m a H e m a t o ló g i c o P ú r p u r a t r o m b o c it o p é n ic a id io p á t ic a
T ip o _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P ú r p u r a H e n o c h - S c h ö n le in
F e c h a d e in ic io :
D is c r a s ia s s a n g u ín e a s
D u r a c ió n :
_ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
D ía s : _ _ _ _ _ _ _
O tro :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
A d e n o m e g a lia s C e r v ic a l
A x ila r
O tro
I n g u in a l
D is e m in a d a s
S ín d r o m e d e R e y e S ín d r o m e d e S t e v e n s J o h n s o n
E v e n to a lé rg ic o F e c h a d e in ic io : D u r a c ió n :
_ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
P a n c r e a t it is D ía s : _ _ _ _ _ _ _
O r q u it is
U r tic a r ia F e c h a d e in ic io : D u r a c ió n :
P a r o t id it is
_ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
E r it e m a n u d o s o D ía s : _ _ _ _ _ _ _
B C G o s is
E d e m a a n g io n e u r ó tic o
L u p u s v u lg a r is
F e c h a d e in ic io :
O s t e o m ie lit is
D u r a c ió n :
_ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
D ía s : _ _ _ _ _ _ _
F e c h a d e in ic io : D u r a c ió n :
S e p t ic e m ia S ín d r o m e d e m u e r t e s ú b it a
R in itis _ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
D ía s : _ _ _ _ _ _ _
E s p e c ific a r
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A n a fila x ia F e c h a d e in ic io : D u r a c ió n :
_ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
D ía s : _ _ _ _ _ _ _
D o lo r a r tic u la r F e c h a d e in ic io : D u r a c ió n :
_ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
D ía s : _ _ _ _ _ _ _
In fla m a c ió n a r tic u la r F e c h a d e in ic io : D u r a c ió n :
_ _ _ _ _ _ _ /_ _ _ _ _ _ _ _ /_ _ _ _ _ _ _
M in u t o s : _ _ _ _ _ _ _ H o r a s : _ _ _ _ _ _ _ _
D ía s : _ _ _ _ _ _ _ H o ja 1 d e 3
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