Child pages
  • Paper forms for SCI ETC

BASIC PATIENT INFORMATION                                                                             

Information provided by:    Patient     Someone else  

        If Someone else : Relation to patient: ____________________

 

Patient name:  Surname _____________________  First name ______________________

Address: District ______________  Chiefdom____________   Town/village ____________

Sex:    Male     Female    

Estimated age:                      YEARS  MONTHS  (for children under 1 year)  

 

 

Form completed by (write your name): ____________________________________

SYMPTOMS and CASE DEFINITION

Number of days since earliest onset of symptoms:                    days

Has the patient had:

1. Sudden onset of a high fever?  YES  NO  UNKNOWN       

2. Contact with a suspect/probable/known Ebola case?  YES  NO  UNKNOWN    

3. Inexplicable bleeding?   YES  NO 

4. Any of the following symptoms (check all that apply)?

 

Headache

Yes    No 

Vomiting

Yes    No 

Anorexia/loss of appetite

Yes    No 

Diarrhoea

Yes    No 

Lethargy/severe fatigue

Yes    No 

Stomach pain

Yes    No 

Aching muscles/joints

Yes    No 

Difficulty swallowing

Yes    No 

Breathing difficulty

Yes    No 

Hiccup

Yes    No 

 

      

* Case definition met if yes for                        OR              OR 

 

Does the patient meet the case definition?  YES  NO 

      If YES : Complete rest of form and send to assessment

      If NO : Ask patient to leave ETC

 

ADDITIONAL PATIENT INFORMATION                                                                             

 

 

Can patient eat:  Nothing      Liquid only     Semi-solid food       Solid food   

 

If Estimated Age is under 12 months (1 year) :  

       Gestation: Term-born ( 37wk GA)    Preterm (<37wk GA)      Unknown 

       Currently breastfed? YES  NO  Unknown   

 

Is the patient a healthcare worker (anyone involved with patient e.g. nurse, hospital cleaner, ambulance driver)?     YES  NO  UNKNOWN       

 

     If YES , Position ____________________ Name of facility ________________________               

                  Location of facility: District ______________ Town/Village ________________

      If NO , Specify occupation ________________________

 

 

Did the patient visit another health centre for this illness (including pharmacy)?  

YES    NO    UNKNOWN       

      If YES , Name of facility ___________________   District _________________________

                  Date visited other facility ( DD/MM/YYYY ) [__][__]/[__][__]/2014   UNKNOWN

                  Patient ID # in other facility ____________________________

 

 

Location where patient became ill:   District_______________________________                   

              Village___________________ Chiefdom ___________________________

 

 

Next of kin: Name ___________________________   Mobile # _____________________

Address:  District _____________________  Town/village _____________________

 

 

Any children (<18 years) at home without supervision?  YES   NO   UNKNOWN               

                  Number of children: [____]      List ages ______________________________