F1 Philippine Malaria Information System (PhilMIS)

Malaria Patient Registry Form (MPRF)

TRANSACTION ID
Case Classification: Indigenous Imported Induced With Case Investigation? TO BE FILLED OUT BY DATA ENCODER

NAME OF FACILITY *
DATE OF CONSULTATION *
Date Blood Examined *
MONTH DAY YEAR
NAME OF PATIENT * MONTH DAY YEAR

Date Result Released *

LAST NAME FIRST NAME M.I.
MONTH DAY YEAR
DATE OF BIRTH
RESULT
AGE YEAR MONTH (IF BELOW 1 Microscopy RDT
YEAR OLD) MONTH YEAR
DAY
Pf Pv Pf
PHILIPPINE MALARIA INFORMATION SYSTEM (PhilMIS)

SEX MALE FEMALE PREGNANT YES NO

Pm Non-Pf
Po
WEIGHT kilo Pf/Non-Pf
Pf/Pv NMPS Pv
IP Group Pf/Pm Pf/Pv
Pv/Pm NEGATIVE
SOURCE OF INCOME/ OCCUPATION
Slide Number RDT Number
ADDRESS
Parasite/µƖ Blood
PUROK/SITIO/ZONE BARANGAY MUNICIPALITY PROVINCE

CHIEF COMPLAINT Fever, if yes temp? ◦C Others Clinical Diagnosis

ONSET OF SYMPTOMS
MONTH DAY 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? YES NO

IF NO, 6 MONTHS PRIOR TO ILLNESS? YES NO

ANTI-MALARIAL DRUGS GIVEN

TOTAL QTY DATE STARTED PREPARATION TOTAL QTY DATE STARTED PREPARATION
Artemether-Lumefantrine Tetracycline
Chloroquine Doxycycline
Primaquine Clindamycin
Quinine tab No Medicine Given
Quinine ampules

DATE MEDICINE GIVEN * SUPERVISED INTAKE OF INITIAL DOSE? YES NO

MONTH DAY 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 YEAR
MONTH DAY YEAR
NAME OF PATIENT Date Result Released *
LAST NAME FIRST NAME M.I. MONTH YEAR
DAY
RESULT
AGE YEAR MONTH (IF BELOW 1
PATIENT'S COPY

YEAR OLD)
YES NO Microscopy RDT
SEX MALE FEMALE PREGNANT
Pf Pv Pf
ADDRESS
Po
Non-Pf
Pm
Pf/Non-Pf
PUROK/SITIO/ZONE BARANGAY MUNICIPALITY PROVINCE Pf/Pv NMPS
Pv
ANTI-MALARIAL DRUGS GIVEN Pf/Pm
Pf/Pv
QUANTITY PREPARATION QUANTITY PREPARATION
Pv/Pm Negative
Artemether-Lumefantrine tabs _____ Tetracycline tabs specify:
Chloroquine tabs _____ Doxycycline tabs specify: Slide Number RDT Number
Primaquine tabs _____ Clindamycin tabs specify:
Quinine tabs _____ No Medicine Given
Quinine ampules tabs _____ Parasite/µƖ blood
REMARK(S)

REFERRED TO
Clinical Diagnosis