Phiippine Integrated Ossease ‘Survelance and Respons Case Investigation Form Coronavirus Disease (COVID-19) [Disease Repartng UnitHoepta: ] Name of avestigator ae af erview RHU - TARANGNAN | I 1. Patent Profile ast Name FirstName Middle Name Birthday (mmidaivyyy)] Age | Sex () Male (Female ‘Ossupaton Gi Sats 7 Nationa Passport a | FILIPINO 2. Philippine Residence 721. Permanent Aaaress House No /LotBiag ManispaliyiCiy Province anaial ea TARANGNAN SAMAR Regon Cetiphane No Eimai adeiess vu ‘22. Current Address | House No,otidg. | SteeVBarangay Municipaliyiy Province TARANGNAN SAMAR Region Home Phone No. Work Phone No, Ema adress j vu 5. Address Outside the Philippines (for Overseas Filipino Workers and Individuals with Residence Oulside the Philippines) Employers Name’ ‘Occupation lace of Work | Howe Bp. Name] Set — Ciytanicpalty | Province | i ] County. [Ofice Phone We. [eelphene No a I Travel History | History of travetvisitworkin other countrios with a (Yes Pont (County) oft ] | known COVID-18 transmission 14 days before the one (he at your signs and symptoms ‘Aiine/Sea vessel ] FlgitVessel | Date of Departore immlaayyyy) a of Arvaln Philppines [ Number 5. Exposure History History of Exposure to Known COVID-T9 Case 14 days (Yes Thyes: Date of Contact with Known COVID-18 | Domed te ree Sone te orp One Case mma) | ()Urknown | Have youtbeen ina place with T y¥es | ives: Pace: ( ) Work place (Heath fai | known COVID-19 transmission 14 (No (Social gathering (C) Religious gathering aye bet matt need () Unknown (Otters: specty type | symptome: | Date wien you have been in that place Name ofthe place st he names of persons who were wih you Gung This ‘Name Contact amber (these) cccasions) and ther contact numbers z Use the back part ofthis shoet when needed 2 7 3. 6. Clinical Information | Rossen (inpatient (1) Outpatient ( ) Discharged ( ) Died ( ) Unknown Date of Onset of ines (mmlaivyn Date of Admision/Consulaion (mmddyy (0 Fever" ( ) Cough (see (eos (0) Shorinessiaiicuty of breathing throat ‘Other signs/symptoms. specify Ts there any history ofather ness? () Yea )Ne 7 _ INYES, spect nea ‘Chest ray done?( ) Yes ) No ‘Are you pregnant?” ( )Yes_( )No tyes, when? te “Assessed as High Risk? ( ) Yes () No ‘CXR Resuts: Preumona { J¥es ( )No( ) Pending Other Radlogi Findings: 3 Information iFYES, Date Galeciod | Date sentto [ate received in RITM POR | Specimen Cotes ee Re OE ari Jus otton Reon | (res own) = | TC Seram ] (J) Oropharyngeal | _onr2a 1 2az0 a | [Nasopharyngeal swab | PC) others ‘Classification (I) Suspect Case [TJ Probable Cone (J Gonfimed Case 8. Outcome Date of Discharge (mmiddyyyyi: | Condiion on Discharge: am | (improved (") Recovered (__) Transfered_(__} Absconded() Died Name of informant (if patient not avaiable) Relatonshi Phone No