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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 such as the patient's identity, residence, travel history, exposure history, clinical information, specimen collection details, and classification. The form is used to gather essential details to identify potential cases and support disease surveillance and response efforts.

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JudeLax
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298 views

Coronavirus Disease (COVID-19) : Case Investigation Form

This document contains a case investigation form for Coronavirus Disease (COVID-19). It collects information such as the patient's identity, residence, travel history, exposure history, clinical information, specimen collection details, and classification. The form is used to gather essential details to identify potential cases and support disease surveillance and response efforts.

Uploaded by

JudeLax
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, 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:
Enderun Mega Swabbing Center
1. Patient Profile
Last Name First Name Middle Name BDATE(mm/dd/yyyy) Age Sex: ( ) Male

( ) Fem.
Occupation Civil Status Nationality Passport No.

2. Philippine Residence
2.1 Permanent Address
House # /Lot /Bldg. Street / Barangay Municipality / City Province

REGION Home Phone # CP # Email

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: N/A Occupation N/A Place of Work: N/A

House No./Bldg. Name N/A Street N/A City/Municipality N/A Province N/A

Country: N/A Office Phone No.: N/A Cellphone No.: N/A


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 the onset ( ) Yes If yes: Date of Contact with Known COVID-19 Case
of signs and symptoms: ( ) No (mm/dd/yyyy):
( ) Unknown
Have you been in a place with a known ( ) Yes If yes: Place: ( ) Workplace ( ) Health facility
COVID-19 transmission 14 days before the ( ) No ( ) Social gathering ( ) Religious gathering
onset of signs and symptoms: ( ) Unknown ( ) Others: specify type:
Date when you have been in that place:
Name of the place:
List the names of persons who were with you during this (these) Name Contact number

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 Is there any history of other 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 Collected Date sent Date received in RITM PCR
Specimen Collected to RITM Virus Isolation Result
(mm/dd/yyyy) (HOUR : MINS) (mm/dd/yyyy) (to be filled up by RITM) Result
_______/
( ) Serum ____/____/____ _______/ ____/____/____
_______
( ) Oropharyngeal/ _______/
____/____/____ _______/ ____/____/____
Nasopharyngeal _______
_______/
( ) Others ____/____/____ _______/ ____/____/____
_______
8. Classification
( ü) Suspect Case ( ) Probable Case ( ) Confirmed Case
9. Outcome
Date of Discharge (mm/dd/yyyy): Condition on Discharge:
Date of Discharge (mm/dd/yyyy):
( ) Improved ( ) Recovered ( ) Transferred ( ) Absconded ( ) Died
Name of Informant: (if patient not available) Relationship: Phone No.

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