Upper and lower respiratory diseases Bronchiolitis Other…………………………….

ILI Diagnosis (Choose one option)

Yes No

Outcome

Cured(e) Alive dead if yes date of death |__|__| / |__|__| /|__|__|__|__|

Number of days of hospitalization: |__|__|

Date of sampling reception: |__|__| / |__|__| /|__|__|__|__| Num of tube: |__|__|__| |__|__|__| |__|__| |__|__|__|__|__|

Area District Year Case number

BIOLOGIC DIAGNOSIS

Flu viruses:

Yes ☐ No ☐

If, yes, specify types: A ☐ B ☐

Sub-types: …………………………………………….

Other viruses:

Yes ☐ No ☐

If yes, specify:…………………………………….……