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    Las Piñas CIF

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    chris

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    © All Rights Reserved
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    Las Piñas CIF

    Uploaded by

    chris
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    3 views1 page

    Las Piñas CIF

    Uploaded by

    chris

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Case Investigation Form

    Philippine Integrated
    Coronavirus Disease (COVID-19)
    Disease
    Unit/Hospital: Las Pinas
    Disease ReportingSurveillance City Health Name of Investigator: Rowena F. Villatito Date of Interview:
    and
    Office Response
    1. Patient Profile
    Last Name First Name Middle Name Birthday Age Sex: ( ) Male ( )Female
    (mm/dd/yyyy)

    Occupation Civil Status Nationality Passport No. N/A


    2. Philippine Residence
    2.1. Permanent Address
    House No./Lot/Bldg. Street/Barangay Municipality/City Province

    Region Home Phone No. Cellphone No. Email address

    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: Occupation Place of Work:
    House No./Bldg. Name Street City/Municipality Province
    Country: Office Phone No.: Cellphone No.:
    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 ( ) Yes If yes: Date of Contact with Known COVID-19 Case
    the onset of signs and symptoms: ( ) No (mm/dd/yyyy) 08/08/2020
    ( ) Unknown
    Have you been in a place with a known COVID-19 If yes: Place: ( ) Work place ( ) Health facility
    transmission 14 days before the onset of signs and ( ) Social gathering ( ) Religious gathering
    symptoms: ( ) Others: specify type:
    ( ) Yes Date when you have been in that place:
    ( ) No Name of the place:
    ( ) Unknown
    List the names of persons who were with you during Name Contact number
    this (these) 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 Loss of smell Is there any history of other illness? () Yes () No If YES, specify:
    Asthma
    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
    Date sent to RITM Date received in
    if YES, Date Collected Virus Isolation
    Specimen Collected (mm/dd/ yyyy) RITM (to be filled up PCR Result
    (mm/dd/yyyy) Result
    by RITM)

    ( ) Serum _____/_____/_____ _____/_____/___ _____/_____/_____


    __
    ( ) Oropharyngeal/ ______/_____/
    Nasopharyngeal ______/____/____ _____ _____/_____/_____
    swab
    _____/_____/
    ( ) Others _____/_____/_____ _____/_____/_____
    _____
    8. Classification
    ( ) Suspect Case ( ) Probable Case ( ) Confirmed Case
    9. Outcome
    Date of Discharge (mm/dd/yyyy): Condition on Discharge:
    ( ) Improved ( ) Recovered ( ) Transferred ( ) Absconded ( ) Died
    Name of Informant: (if patient not available) Relationship: Phone No.

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