Nothing Special   »   [go: up one dir, main page]
Scribd Logo
Upload

Welcome to Scribd!

  • 279 views

    Coronavirus Disease (COVID-19) : Case Investigation Form

    Uploaded by

    JudeLax
    This document contains a case investigation form for Coronavirus Disease (COVID-19). It collects information such as the patient's identity, residence, travel history, exposure history, clinical information, specimen collection details, and classification. The form is used to gather essential details to identify potential cases and support disease surveillance and response efforts.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    Coronavirus Disease (COVID-19) : Case Investigation Form

    Uploaded by

    JudeLax
    279 views2 pages
    This document contains a case investigation form for Coronavirus Disease (COVID-19). It collects information such as the patient's identity, residence, travel history, exposure history, clinical information, specimen collection details, and classification. The form is used to gather essential details to identify potential cases and support disease surveillance and response efforts.

    Original Title

    New Cif Form

    Copyright

    © © All Rights Reserved

    Available Formats

    XLSX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document contains a case investigation form for Coronavirus Disease (COVID-19). It collects information such as the patient's identity, residence, travel history, exposure history, clinical information, specimen collection details, and classification. The form is used to gather essential details to identify potential cases and support disease surveillance and response efforts.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    279 views2 pages

    Coronavirus Disease (COVID-19) : Case Investigation Form

    Uploaded by

    JudeLax
    This document contains a case investigation form for Coronavirus Disease (COVID-19). It collects information such as the patient's identity, residence, travel history, exposure history, clinical information, specimen collection details, and classification. The form is used to gather essential details to identify potential cases and support disease surveillance and response efforts.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    You are on page 1of 2

    Philippine Integrated Disease

    Surveillance and Response


    Case Investigation Form
    Coronavirus Disease (COVID-19)
    Disease Reporting Unit/Hospital: Name of Investigator: Date of Interview:
    Enderun Mega Swabbing Center
    1. Patient Profile
    Last Name First Name Middle Name BDATE(mm/dd/yyyy) Age Sex: ( ) Male

    ( ) Fem.
    Occupation Civil Status Nationality Passport No.

    2. Philippine Residence
    2.1 Permanent Address
    House # /Lot /Bldg. Street / Barangay Municipality / City Province

    REGION Home Phone # CP # Email

    2.2 Current Address


    House No./Lot/Bldg. Street/Barangay Municipality/City Province

    Region Home Phone No. Work Phone No. Other Email address

    3. Address Outside the Philippines (for Overseas Filipino Workers and Individuals with Residence Outside the Philippines)
    Employer's Name: N/A Occupation N/A Place of Work: N/A

    House No./Bldg. Name N/A Street N/A City/Municipality N/A Province N/A

    Country: N/A Office Phone No.: N/A Cellphone No.: N/A


    4. Travel History
    History of travel/visit/work in other countries with a known COVID-19 ( ) Yes Port (Country) of exit:
    transmission 14 days before the onset of your signs and symptoms: ( ) No
    Airline/Sea vessel: Flight/Vessel Number: Date of Departure (mm/dd/yyyy) Date of Arrival in Philippines:

    5. Exposure History
    History of Exposure to Known COVID-19 Case 14 days before the onset ( ) Yes If yes: Date of Contact with Known COVID-19 Case
    of signs and symptoms: ( ) No (mm/dd/yyyy):
    ( ) Unknown
    Have you been in a place with a known ( ) Yes If yes: Place: ( ) Workplace ( ) Health facility
    COVID-19 transmission 14 days before the ( ) No ( ) Social gathering ( ) Religious gathering
    onset of signs and symptoms: ( ) Unknown ( ) Others: specify type:
    Date when you have been in that place:
    Name of the place:
    List the names of persons who were with you during this (these) Name Contact number

    occasion(s) and their contact numbers: 1

    Use the back part of this sheet when needed 2

    3
    6. Clinical Information
    Disposition at Time of Report ( ) Inpatient ( ) Outpatient ( ) Discharged ( ) Died ( ) Unknown
    Date Of Onset of Illness (mm/dd/yyyy): Date of Admission/Consultation (mm/dd/yyyy)

    Fever ____________°C ( ) Cough ( ) Sore throat ( ) Colds ( ) Shortness/difficulty of breathing


    Other signs/symptoms, specify Is there any history of other illness? ( ) Yes ( ) No
    If YES, specify:
    Chest X-ray done? ( ) Yes ( ) No Are you pregnant? ( ) Yes ( ) No
    If yes, when? ______________________________ LMP _______________________ Assessed as High Risk? ( ) Yes ( ) No

    Cxr Results: Pneumonia ( ) Yes ( ) No ( ) Pending Other Radiologic Findings:


    7. Specimen Information
    If YES, Date Collected Date sent Date received in RITM PCR
    Specimen Collected to RITM Virus Isolation Result
    (mm/dd/yyyy) (HOUR : MINS) (mm/dd/yyyy) (to be filled up by RITM) Result
    _______/
    ( ) Serum ____/____/____ _______/ ____/____/____
    _______
    ( ) Oropharyngeal/ _______/
    ____/____/____ _______/ ____/____/____
    Nasopharyngeal _______
    _______/
    ( ) Others ____/____/____ _______/ ____/____/____
    _______
    8. Classification
    ( ü) Suspect Case ( ) Probable Case ( ) Confirmed Case
    9. Outcome
    Date of Discharge (mm/dd/yyyy): Condition on Discharge:
    Date of Discharge (mm/dd/yyyy):
    ( ) Improved ( ) Recovered ( ) Transferred ( ) Absconded ( ) Died
    Name of Informant: (if patient not available) Relationship: Phone No.

    You might also like