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Puerperal Fever

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					                                        Infectious Disease Certificate
                     Disease Surveillance Unit - Department of Public Health - 37-39 Rue D'Argens Msida - Malta MSD05
                                         Tel: +356 2133 2235, +356 21311774 - Fax: +356 2131 9243
                                    Email: disease.surveillance@gov.mt - Website: www.health.gov.mt/dsu
Patient data
         Name                                                              ID No.

        Surname                                                     Patient Code




         Tel No.                                                              Male               Female

    Employment                                                                 Age

         Address




is suffering from:
      Acquired Immune Deficiency                Granular conjunctivitis / trachoma               Puerperal fever
      Syndrome (AIDS)                           Haemophilus influenza group B                    Q-fever
      Acute encephalitis                        Hepatitis A                                      Rabies
      Acute flaccid paralysis                   Hepatitis B                                      Rubella
      Anthrax                                   Hepatitis C                                      Salmonellosis
      Antimicrobial Resistance                  HIV-Infection                                    Scarlet fever
      Bacterial meningitis, other than          Influenza                                        Severe Acute Respiratory Syndrome
      meningococcal                             Legionellosis                                     (SARS)
      Botulism                                  Leishmaniasis                                    Shigellosis
      Brucellosis                               Leprosy                                          Smallpox
      Campylobacteriosis                        Leptospirosis                                    Syphilis
      Chickenpox/Shingles                       Listeriosis                                      Tetanus
      Chlamydia infection                       Louse borne relapsing fever                      Toxoplasmosis
      Cholera                                   Malaria                                          Transmissible spongiform
      Congenital rubella syndrome               Measles                                          encephalopathies, variant
      Cryptosporidiosis                         Meningococcal disease                            Creutzfeldt-Jakob disease (vCJD)
      Dengue Fever                              Mumps                                            Trichinosis
      Diphtheria                                Nosocomial Infection                             Tuberculosis
      Dysentery (amoebic and bacillary)       Hospital ___________________                       Tularaemia
      Echinococcosis                          Infection site ________________________            Typhoid fever
      Erysipelas                                 Pertussis                                       Typhus
      E. coli: Enterohaemorrhagic                Plague                                          Viral haemorrhagic fever
      Food borne illness                         Pneumococcal infection                          Yellow fever
      Giardiasis                                 Pneumonia                                       Yersinosis
      Gonococcal Infection                       Poliomyelitis


Doctor data
        Name                                                              Tel No.
        Surname                                                          Reg No.

                                                                             Date

        Signature    __________________________
                     IN CASES REQUIRING URGENT ACTION PLEASE CONTACT ST. LUKE’S HOSPITAL ON
                                                           21241251/25950000
All data is collected in accordance with Article 27 (a) (i) of the Public Health Act and the Data protection Act 2001. The data is
required for control measures, statistics and research purposes in the interest of public health.                       DPH 35

				
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posted:8/8/2010
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Description: Puerperal Fever