Annex N: Home Isolation Patient Monitoring Sheet

Home Isolation Patient Monitoring Sheet

/____/__ ________
Confinned C.ase ID:________________ Start Date of Clinical Support: ..,....... Min Isolation Period*: __ Region:.___
Patient Name: --------------=-c::-----;-----=-----,----------...,, Date of Symptom Onset: -,--....;/__....;/�--=--==-End of Isolation Period Date: -
/__,,.. -
Vaccine Status:-,--_________ Vaccine Brand: __.....,...._____ Date of 1st dose: --/--/___ Date of 2nd dose: --/--/___ Date of Booster: - / /___
Healthcare Worker or employee from an authoriz.ed sector (Yes/No):__,,.____,___,,--..,,....- - �:-. -
Instructions: MonitoriDg should be done twice a day, once in the morning and once in the afternoon/ evening. Indicate the date and go through each item Put a check if a patient has the symptom upon monitoring in the
�� 1
correct column {AM/PM) and indicate temperature taken (ie. 38Q.
.
- '
Dayl Day2 Day3 Dav4 Day5 Day6 Day7 Day8 Day9 DaylO Dav.11 Day12 :Day13 Day14
Date: -
-
AM
Temp
PM
-
AM
Oxygen
PM -
-
Coueh(ubo)
.. ,-
-
Chills
Fati2Ue/im:dness (oae.kaoagod)
� ·-� --
Body oain (Sakit 11!!: Katawan)
Headache (Sakit 11!!: Ulo)
Loss of Taste and Smell
'
(Pa2kawala o bawas ruroanlasa o
Sore Throat (masaki.t all!!: lalamunan)
Congestion or runny nose (Sipon na bakabara o

=
tumutulo)
Diarrhea (Basa o labis oa2:dudllll11)
Nausea/Vomitine:
..•
(Naduduwal onagsusuka)
a�a s�usunod na sintomas)
·.;; · . .. ... . . "'
:' Red fllll!'s (rii-re�brt ae:ad kun{ mariu1asan
Shonness of Breath or Difficulty in breathing

�-
•. '
(Hirap sa
Persistent Pain or Pressure in the Oiest
(sakit o bigat sa dibdib na di nawawala)
Confusion f"' • ' Da2:kalito)
Difficulty in waking up or sleeping
Oiiran
-
matulo!! 0 ma!1'isirn,,)
Pale, gray, or bluish lips or nailbeds (pagbabago ng n,
kulav� balat, Jabi, o kuko)
Others ([bang sintomas):
1,
2.
Assessed and monitored by.

Doctor/Nur.ie of the Home Isolation Team Printed Name and Signatw-e ·-

Designation
*Btued 011 prevailiflg C/i11i&al Pror.ice Guidelines a.r adopted ltY the Deport,ne11t efHealth (DOH) Page 1 of 1 of Annex N