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BIBLIOGRAPHIC INPUT SHEET TEMPORARY Patterns of mortality ...

BIBLIOGRAPHIC INPUT SHEET TEMPORARY Patterns of mortality ...

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,83O6 Patten <strong>of</strong>-Mortality in Childhood<br />

INTER-AMERICAN INVESTIGATION OF MORTALITY, INCHILDHOOD<br />

Confidential Death page 51"<br />

4Name <strong>of</strong> child<br />

Serial no.<br />

Dae fDate <strong>of</strong> Sex Age at<br />

Sbirth ,death death Yr,. __.moN. days. h.. .<br />

PRESENT ILLNESS - EVENTS THAT LED TO DEATH OF THE CHILD<br />

6Z. Date disease started 63. How disease started<br />

64. Main symptoms<br />

65, Description <strong>of</strong> disease<br />

PHYSICAL EXAMINATION (at admission to hospital or first outpatient or house visit)<br />

66. Date _ 67. Height_ 68. Weight and arm circumference: Wt. _ Arm circumference<br />

69. Nutritional status.<br />

70. Relevant physical findings_<br />

71 Evolution and treatment<br />

.72. Soure <strong>of</strong> I I Private I Other C" Dt<br />

inforsmiAt: Hospital 7 Clinic 13 . 0. Oe Date Interviewer

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