Viral Haemorrhagic Fever Contact Daily Monitoring Form

Name of patient: _______________________________________ ID-number GPS coordinates: Latitude: ° ‘

Longitude: ° ‘

Name of contact:_______________________________________ Sex: F M Age:________________ (years)

Date of last contact (dd/mm/yy): ___________________ Address:______________________________________Telephone number:_______________________

Type of contact in the last 21 days: 1. Touched fluid of a patient 2. Direct physical contact (dead or Alive) 3. Manipulation of cloths or other objects
4. Was in the same room or house with Patient

Contact through hospital Y / N Name of hospital:__________________________________ Date of 1 st visit_____________

Household information: No. of rooms

No. living in household: No. of conveniences: Are conveniences shared? Y / N
Dates

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Fever (take temperature)
Malaise
Muscle pain
Headache
Pharyngitis
Vomiting
Diarrhoea
Maculo-papular rash
Haemorrhagic sign

Other comments on contact:.........................................................................................................................................................................................

VHF Contact Daily Monitory Form, version 11 January 2016