Wiki Spaces


Get Help from Others

Q&A: Ask OpenMRS
Discussion: OpenMRS Talk
Real-Time: IRC Chat | Slack


Page tree

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): ____________________________________


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)?



Yes    No 


Yes    No 

Anorexia/loss of appetite

Yes    No 


Yes    No 

Lethargy/severe fatigue

Yes    No 

Stomach pain

Yes    No 

Aching muscles/joints

Yes    No 

Difficulty swallowing

Yes    No 

Breathing difficulty

Yes    No 


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 ______________________________