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