Please enter date of Activity
How many people living in the household
How many males living in the household
How many females living in the household
Is there any person with onset of fever with Sore Throat and (or) Cough?
How many persons are showing these symptoms?
Have you seen or heard of anyone within the neighbourhood who has recent onset of fever with Sore Throat and (or) Cough?
Where has the suspected Diphtheria case taken to for treatment?
Enter Age (of case) in Years
Occupational Status (of case)
