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    Borang DRS Annex1

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    justforlazada

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    Borang DRS Annex1

    Uploaded by

    justforlazada
    9 views1 page

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    Download as docx, pdf, or txt
    9 views1 page

    Borang DRS Annex1

    Uploaded by

    justforlazada

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    DRS_Annex1

    National Surveillance of Drug Response Against


    Malaria Parasite (P.falciparum, P.vivax, P.malariae, P.ovale and P.knowlesi)

    Note: This form is to be completed for all cases of P.falciparum, P.vivax, P.malariae, P.ovale and P.knowlesi seen and treated with
    the first line drugs at the all hospitals/clinics.

    INFORMANT
    1 Hospital State
    Name of Reporting Officer Designation of Reporting Officer
    Medical Officer
    Coordinator
    2
    PATIENT'S DEMOGRAPHIC DATA
    Patient's Initial Patient's ID (Reg. No/NRIC)
    Gender ( / ) Body
    Age (Years) Ethnic
    Male Female weight
    3
    DRUG/MEDICATION HISTORY
    Actual number of tablet given to and taken by the patient
    Day of treatment ASMQ Others (Specify) :
    AL
    Adult dose Paeds dose
    D0
    D1
    D2
    4
    PARASITE RESPONSE
    P.falciparum P.vivax P.malariae
    Type of parasite ( / )
    P.ovale
    P.knowlesi
    Follow-up slide post treatment Parasite density (per UL blood)
    Day Date Due* Actual Date** Asexual Sexual (gametocyte)
    D0
    D3
    D7
    D14
    D21
    D28
    D42
    5
    CASE INVESTIGATION
    Was this patient treated before for No
    malaria ( / ) Yes
    What type of medication ? (if known)
    When was medication taken ?
    (eg : 1 week/month prior to current
    treatment)
    Probable Source of Infection in This Local
    Case ( / )
    Imported From where?

    6 VERIFICATION AND VALIDATION (Epid. Officer/MOH)


    Name Signature

    AL= Artementher-Lumefantrine (Riamet) ASMQ=Artesunate-Mefloquine


    D0= Day of starting the treatment
    * Enter the day due for the subsequent post-treatment follow-up (D3,D7,D14,D21,D28,D42)
    ** Enter the actual date of slide collection during follow-up

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