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Coronavirus Disease (COVID-19) : Case Investigation Form

This document contains a case investigation form for Coronavirus Disease (COVID-19). It collects information about a patient's identity, residence, travel history, exposure history, clinical information, specimen collection, disease classification, and outcome. Details include the patient's name, address, occupation, travel to countries with COVID-19 transmission, contact with known COVID-19 cases, signs and symptoms, chest X-ray results, specimen collection dates and test results, and condition upon discharge. The form is used to gather essential details to identify, manage, and classify suspected or confirmed COVID-19 cases.

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Babiejoy Beltran Acelo
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126 views1 page

Coronavirus Disease (COVID-19) : Case Investigation Form

This document contains a case investigation form for Coronavirus Disease (COVID-19). It collects information about a patient's identity, residence, travel history, exposure history, clinical information, specimen collection, disease classification, and outcome. Details include the patient's name, address, occupation, travel to countries with COVID-19 transmission, contact with known COVID-19 cases, signs and symptoms, chest X-ray results, specimen collection dates and test results, and condition upon discharge. The form is used to gather essential details to identify, manage, and classify suspected or confirmed COVID-19 cases.

Uploaded by

Babiejoy Beltran Acelo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Philippine Integrated Disease

Surveillance and Response Case Investigation Form


Coronavirus Disease (COVID-19)
Disease Reporting Unit/Hospital: Name of Investigator: Date of Interview:
CITY HEALTH OFFICE
1. Patient Profile
Last Name First Name Middle Birthday (mm/dd/yyyy) Age Sex: ( ) Male
Name ( ) Female
Occupation Civil Status Nationality Passport No.
FILIPINO N/A
2. Philippine Residence
2.1. Permanent Address
House No./Lot/Bldg. Street/Barangay Municipality/City Province
CITY OF SAN JOSE DEL MONTE BULACAN
Region Home Phone No. Cellphone No. Email address
III N/A
2.2. Current Address
House No./Lot/Bldg. Street/Barangay Municipality/City Province
CITY OF SAN JOSE DEL MONTE BULACAN
Region Home Phone No. Work Phone No. Email address
III N/A N/A N/A
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 ( ) Yes Port (Country ) of exit:
COVID-19 transmission 14 days before the onset of your signs ( ) No
and
symptoms:
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-
the onset of signs and symptoms: ( )No 19 Case (mm/dd/yyyy):
( )Unknown
Have you been in a place with a known ( ) Yes If yes: Place: ( ) Work place ( ) Health facility
COVID- 19 transmission 14 days before the ( ) No ( ) Social gathering ( ) Religious gathering
onset of signs and symptoms: ( ) Unknown ( ) Others: specify type: _ _ ________________

PHILHEALTH NO. Date when you have been in that place:


NO. OF FAMILY MEMBERS IN ONE HOUSE: Name of the place:
List the names of persons who were with you during this Name Contact number
(these) occasion(s) and their contact numbers: 1.
Use the back part of this sheet when needed 2.
t
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 ofother 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 Date sent to Date received in RITM Virus
Specimen Collected PCR
Collected RITM (mm/dd/ (to be filled up by RITM) Isolation
Result
(mm/dd/yyyy) yyyy) Result
( ) Serum

(X) 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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