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  • F1 Malaria Patient Registry Form

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    Cha Tuban Diana
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    This document contains a malaria patient registry form used in the Philippine Malaria Information System (PhilMIS) to collect patient data. The form collects identifying information about patients such as name, age, sex, address and occupation. It also collects clinical information such as symptoms, test results, diagnosis and treatment. Test results can include the type of malaria parasite detected by microscopy or rapid diagnostic test. Treatment information includes the name, dosage and date of any anti-malarial drugs administered. The form is used to register both indigenous and imported malaria cases.

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    Malaria

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    This document contains a malaria patient registry form used in the Philippine Malaria Information System (PhilMIS) to collect patient data. The form collects identifying information about patients such as name, age, sex, address and occupation. It also collects clinical information such as symptoms, test results, diagnosis and treatment. Test results can include the type of malaria parasite detected by microscopy or rapid diagnostic test. Treatment information includes the name, dosage and date of any anti-malarial drugs administered. The form is used to register both indigenous and imported malaria cases.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    224 views1 page

    F1 Malaria Patient Registry Form

    Uploaded by

    Cha Tuban Diana
    This document contains a malaria patient registry form used in the Philippine Malaria Information System (PhilMIS) to collect patient data. The form collects identifying information about patients such as name, age, sex, address and occupation. It also collects clinical information such as symptoms, test results, diagnosis and treatment. Test results can include the type of malaria parasite detected by microscopy or rapid diagnostic test. Treatment information includes the name, dosage and date of any anti-malarial drugs administered. The form is used to register both indigenous and imported malaria cases.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Philippine Malaria Information System (PhilMIS)

    F1

    Malaria Patient Registry Form (MPRF)

    Case Classification:

    Indigenous

    NAME OF FACILITY

    TRANSACTION ID

    Induced With Case Investigation?

    TO BE FILLED OUT BY DATA ENCODER

    DATE OF CONSULTATION
    NAME OF PATIENT

    Imported

    MONTH

    YEAR

    DAY

    MONTH

    FIRST NAME

    M.I.

    MONTH

    DATE OF BIRTH

    PHILIPPINE MALARIA INFORMATION SYSTEM (PhilMIS)

    SEX

    DAY

    YEAR

    Date Result Released

    LAST NAME

    AGE

    Date Blood Examined

    FEMALE

    MONTH

    PREGNANT

    YEAR

    DAY

    YES

    NO

    kilo

    WEIGHT

    RDT

    Microscopy

    YEAR OLD)

    MALE

    YEAR

    RESULT

    MONTH (IF BELOW 1

    YEAR

    DAY

    IP Group
    SOURCE OF INCOME/ OCCUPATION

    Pf

    Pv

    Pm

    Po

    Pf/Pv

    NMPS

    Pf
    Non-Pf
    Pf/Non-Pf
    Pv

    Pf/Pm

    Pf/Pv

    Pv/Pm

    NEGATIVE

    Slide Number

    RDT Number

    ADDRESS
    PUROK/SITIO/ZONE

    BARANGAY

    CHIEF COMPLAINT

    MUNICIPALITY

    Fever, if yes temp?

    Parasite/ Blood

    PROVINCE

    Clinical Diagnosis

    Others

    ONSET OF SYMPTOMS
    DAY

    MONTH

    YEAR

    HISTORY OF TRAVEL FOR THE PAST TWO WEEKS?

    YES

    NO

    WHERE?

    HEALTH FACILITY'S COPY

    HISTORY OF BLOOD TRANSFUSION 2 WEEKS PRIOR TO ONSET OF ILLNESS?


    IF NO, 6 MONTHS PRIOR TO ILLNESS?

    YES

    NO

    YES

    NO

    ANTI-MALARIAL DRUGS GIVEN


    TOTAL QTY

    DATE STARTED

    PREPARATION

    TOTAL QTY

    Chloroquine
    Primaquine
    Quinine tab
    Quinine ampules
    DATE MEDICINE GIVEN

    DATE STARTED

    PREPARATION

    Tetracycline
    Doxycycline
    Clindamycin
    No Medicine Given

    Artemether-Lumefantrine

    YES

    SUPERVISED INTAKE OF INITIAL DOSE?


    MONTH

    DAY

    NO

    YEAR

    HEALTH WORKER WHO


    ADMINISTER THE MEDICINE
    LAST NAME

    FIRST NAME

    M.I.

    DESIGNATION
    DISPOSITION OF PATIENT (TO BE FILLED OUT WHEN CONSULTING RHU OR PHYSICIAN)

    Referred

    Died

    REFERRED TO
    REASON FOR REFERRAL &/OR REMARKS
    CUT THIS PORTION
    NAME OF FACILITY

    Date Blood Examined

    DATE OF CONSULTATION
    MONTH

    DAY

    MONTH

    YEAR

    NAME OF PATIENT

    PATIENT'S COPY

    SEX

    FIRST NAME

    MONTH

    YEAR

    M.I.

    MONTH

    YES

    NO

    PREGNANT

    ADDRESS
    BARANGAY

    MUNICIPALITY

    PROVINCE

    YEAR

    RDT

    Microscopy
    Pf

    Pv

    Pm

    Po

    Pf/Pv

    NMPS

    Pf/Pm

    ANTI-MALARIAL DRUGS GIVEN


    QUANTITY

    DAY

    PREPARATION

    QUANTITY

    PREPARATION

    Pv/Pm

    Artemether-Lumefantrine

    tabs

    _____

    Tetracycline

    tabs

    specify:

    Chloroquine

    tabs

    _____

    Doxycycline

    tabs

    specify:

    Primaquine

    tabs

    _____

    Clindamycin

    tabs

    specify:

    Quinine

    tabs

    _____

    No Medicine Given

    Quinine ampules

    tabs

    _____

    Slide Number

    Parasite/ blood

    REMARK(S)
    REFERRED TO

    RESULT

    (IF BELOW 1
    YEAR OLD)

    FEMALE

    MALE

    PUROK/SITIO/ZONE

    YEAR

    Date Result Released

    LAST NAME

    AGE

    DAY

    Clinical Diagnosis

    Pf
    Non-Pf
    Pf/Non-Pf
    Pv
    Pf/Pv
    Negative
    RDT Number

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