ONLINE - OUTPATIENT CIF REGISTRATION - Ver.

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Disease Reporting Unit * : DRU Region and Province: Philhealth No:

DR. PABLO O. TORRE MEMORIAL HOSPIT Region VI (Western Visayas) 112522813713

Name of Interviewer: Contact Number of Interviewer: DATE OF INTERVIEW:

-- -- 09/15/2022
Name of Informant: Relationship: Contact Number of Informant:

-- -- --

If existing case (check all that apply)*

Not Applicable (New Case)
Update Case Classification
Update Disposition

Not Applicable (Unknown)
Update Vaccination
Update Exposure/Travel History

Update Symptoms
Update Lab Result
Others, Specify

Update Health Status/Outcome
Update Chest Imaging Findings

Type of Client:

COVID-19 Case (Suspect,
Close Contact
For RT-PCR Testing (Not A
Probale Or Confirmed) Case Of Close Contact)

APPENDIX 1: TESTING CATEGORY/SUB-GROUP

SUB-GROUP

A Individuals with severe/critical symptoms and relevant history of travel/or contact

Individuals with mild symptoms and relevant history and/or contact, and considered vulnerable. Vulnerable populations include those
B elderly and with preexisting medical conditions that predispose them to severe presentation and complications of COVID-19

C Individuals with mild symptoms, and relevant history of travel and/or contact

D Individuals with no symptoms but with relevant history of travel and/or contact or high risk of exposure. These include:

D1 Contact-traced individuals

D2 Healthcare workers, who shall be prioritized for regular testing in order to ensure the stability of our healthcare system

D3 Returning Overseas Filipino Worker, who shall immediately be tested at the port of entry

Filipino citizens in a specific locality w/n the Philippines who have expressed intention to return to their place of residence/home origin
D4 (Locally stranded Individuals) may be tested subject to the existing protocols of the IATF

E Frontliners indirectly involved in health care provision in the response against COVID-19 may be tested as follows
 Those with high or direct exposure to COVID-19 regardless of location may be tested up to once a week. These include the following:
a) personnel manning the Temporary Treatment and Quarantine Facilities (LGU-and Nationally-managed);
b) Personnel serving at the COVID-19 swabbing Center;
E1 c) Contact tracing personnel; and
d) Any personnel conducting swabbing for COVID-19 testing

Those who do not have high or direct exposure to COVId-19 but who live or work in Special Concerns Areas may be treated up to every
two to four weeks. These include the following:
a) Personnel manning Quarantine Control Points, including those from Armed Forces of the Philippines, Bureau of Fire Protection ,
and others;
b) National/Regional /Local Risk Reduction and Management Teams;
c) Officials from any local government/city/municipality health office (CEDSU,CESU, etc);
E2 d) Barangay Health Emergency Response Teams and barangay officials providing barangay border control and performing COVID-
19 related tasks;
e) Personnel of Bureau of Corrections and Bureau of Jail Penology and Management;
f) Personnel manning the One-Stop-sjop in the Management of the Returning Overseas Filipinos;
g) Border control of patrol officers, such as immigration officers of the Returning Overseas Filipinos; and
h) Social workers providing amelioration and relief assistance to communities and performing COVID-19 related tasks.

Other vulnerable patients and those living in confined spaces. These include, but are not limited to:
a) Pregnant patients who shall be tested during the peripartum period;
b) Dialysis patients;
c) Patients who are immunocompromised, such as those have HIV/AIDS, inherited diseases that affect the immune system;
F d) patients undergoing chemotherapy or radiotherapy;
e) patients who will undergo elective surgical procedures with high risk for transmission;
f) Any person who have had organ transplants, or have had bone marrow or stem cell transplant in the past 6 months;
g) Any person who is about to be admitted in enclosed institutions such as jails, penitentiaries, and mental institutions.

Residents, occupants or workers in a localized area with an active COVID-19 cluster, as identified and declared by the local chief executive
in accordance with existing DOH Guidelines and consistent with the National Task Force Memorandum Circular No. 02 s2020 or the
G Operational Guidelines on the Application of the Zoning Containment Strategy in the Localization of the National Action Plan Against
COVID-19 Response. The Local Chief Executive shall conduct the necessary testing in order to protect the broader community and critical
economic activities and to avoid a declaration of a wider community quarantine

H Frontliners in Tourist Zones:

All workers and employees in the hospitality and tourism sectors in El Nido, Boracay, Coron, Panglao, Siargao and other tourist zones, as
H1 identified and declared by the Department of tourism. These and employees may be tested once every four (4) weeks.

All travelers, whether of domestic or foreign origin, may be tested at least once, at their own expense, prior to entry into any designated
H2 tourist zone, as identified and declared by the Department of Tourism

All workers and employees of manufacturing companies and public service providers registered in economic zones located in Special
I Concern Areas may be tested regularly. In order to re-open the economy safely, the covered economic zone employees may be test every
quarter.

J Economy Workers
 Frontline and Economic Priority Workers, defined as those
1) who work in high priority sectors, both public and private,
2) have high interaction with and exposure to the public, and
3) who live or work in Special Concerns Areas, may be tested every three (3) months. These include but not limited to:

a) Transport and Logistics:

                    - Drivers of Taxis, Ride Hailing Services (2 or 4 wheels), Buses, Public Transport Vehicle,
Conductors, Pilots, Flight
Attendants, flight Engineers, Rail Operators, mechanics,
servicemen, Delivery Staff, Water Transport workers (ferries, inter-island
shipping, ports)
b) Food Retails

           - Waiters, Waitress, Bard Attendants, Baristas, Chefs and Cooks, Restaurant Managers and Supervisors
c) Education:

           - Teachers at all levels of education, Other school frontliners such as guidance counselors, librarian, cashiers
d) Financial Services

           - Bank Tellers

J1 e) Non-Food Retails
           - Cashiers, Stock Clerks, Retail Salespersons
f) Services
           - Hairdressers, Barbers, manicurist, pedicurist, massage Therapists, Embalmers,
Morticians, Undertakers, Funeral Directors,
Parking Lot Attendants, Security Guards,
Messengers
g) Construction
           - Carpenters, Stonemasons, Electricians, painters, Construction workers
including Foreman, Supervisors, Civil Engineers,
Structural Engineers, Construction
Managers. Crane and Tower Operators, Elevator installers and repairs
h) Water Supply, Sewerage, Waster Management
           - Plumbers, Recycling and Reclamation workers, Garbage Collectors,
Water/Wastewater Engineers, Janitors and Cleaners
I) Public Sector
           - Judges, courtroom clerks, staff and security, all national and local government
employees rendering frontline services in
special Concerns Areas
J) Mass Media
           - Field Reporters, photographers and cameramens

All employees not covered above are not required to undergo testing but are encouraged to be tested every quarter. Private sector
J2 employers are highly encouraged to send their employees for regular testing at the employers’ expense in order to avoid lockdowns that
may do more damage to their companies

Part 1. Patient Information

       1.1 Patient Profile

LASTNAME *: FIRSTNAME (and Suffix) *: MIDDLENAME *:

ARBUYA MA. LINDY CAMPONION

DATE OF BIRTH *: AGE *: SEX *:

03/05/2000 22 Female

CIVIL STATUS *: NATIONALITY *:

Single FILIPINO
OCCUPATION Works In Closed Settings?

STUDENT
Yes

No

Unknown

       1.2 Current Address * (Provide address of institution if patient lives in closed settings, see 1.5)

House #/Lot/Building or any Landmark *: Street/Purok/Sitio *: BRGY./STREET *:

Barangay 5 (Pob.)
Canlaon View Subdivision Almaciga St.

Municipality/City/District *: PROVINCE *: REGION *:

MURCIA Negros Occidental Region VI (Western Visayas)

HOME PHONE NO : CELLPHONE NO. * EMAIL ADDRESS :

09475872668 arbuyalindy@yahoo.com

       1.3 Permanent Address (if different from current address)

 House #/Lot/Building or any Landmark *: Street/Purok/Sitio *: BRGY *:

Barangay 5 (Pob.)
Canlaon View Subdivision Almaciga St.

Municipality/City/District *: PROVINCE *: REGION *:

CITY OF BACOLOD (CAPITAL) Negros Occidental Region VI (Western Visayas)

HOME PHONE NO : CELLPHONE NO. * EMAIL ADDRESS :

09475872668 arbuyalindy@yahoo.com

       1.4 Current Workplace Address and Contact Information

LOT/BLDG. NAME : Street/Purok/Sitio: BRGY./STREET:

Barangay 40 (Pob.)
University of Negros Occidental-Recoleto Lizares St.

CITY/MUNICIPALITY: PROVINCE: Name of Workplace:

CITY OF BACOLOD (CAPITAL) Negros Occidental

University of Negros Occidental-Recoleto

PHONE NO./CELLPHONE NO. EMAIL ADDRESS

-- --

       1.5 Special Population (indicate further details on exposure and travel history in Part 3)

Health Care Worker *

Yes
Name of Health Facility
and location

No
Returning Overseas Filipino *
Yes
Country of Origin
and Passport Number

No
OFW *
OFW

Non-OFW

Foreign National Traveler*

Yes
Country of Origin
and Passport Number

No
Locally Stranded

Yes
City, Municipality, & Province of Origin

No
Individual/APOR/Local Traveler*

 
Locally Stranded Individual

Authorized Person Outsode Residence/Local Traveler

NA

Lives in Closed Setting*

Yes
Institution Type and Name

No

(e.g. prisons, residential facilities, retirement communities, care homes, camps, etc.)

Part 2. Case Investigation Details

       2.1 Consultation Information

Have previous COVID-19 related

Yes
Date of First Consultation MM/DD/YYYY

No
consultation?
Name of facility where first consult
was done

       2.2 Disposition at Time of Report * (Provide name of hospital/isolation/quarantine facility)

Admitted In Hospital Name Of Hospital: Date And Time Admitted In Hospital:

Admitted In Isolation/Quarantine Facility Name Of Quarantine Facility: Date And Time Isolated/Quarantined At
Facility:

In Home Isolation/Quarantine Date And Time Isolated/Quarantined At
Home:

Discharged At Home If Discharged: Date Of
Others
Discharge(MM/DD/YYYY):

       2.3 Health Status at Consult*

Asymptomatic
Mild
Moderate
Sever
Critical

       2.4 Case Classification*

Suspect
Probable
Confirmed
Non-COVID-19 Case

       2.5 Vaccination Information*

Date Of Vaccination Name Of Vaccine Dose Number (Eg. 1st,2nd)

Vaccination Center/Facility
Region Of Health FacilityAdverse Event/s?

10/08/2021 PFIZER 1ST MURCIA HEALTH OFFICEREGION VI

YES

NO
Date Of Vaccination Name Of Vaccine Dose Number (Eg. 1st,2nd)
Vaccination Center/Facility
Region Of Health FacilityAdverse Event/s?

11/08/2021 PFIZER 2ND MURCIA HEALTH OFFICEREGION VI

YES

NO

       2.6 Clinical Information

Date of Onset of Illness (MM/DD/YYYYY)*:

MM/DD/YYYY
Signs and Symptoms (Check all that apply if present)

Asymptomatic
Dyspnea

TEMP in Celsius
Anorexia
Fever

Cough
Nausea

General Weakness
Vomitting

Fatigue
Diarrhea

Headache
Altered Mental Status

Myalgia
Anosmia (Loss Of Smelll, W/O Any Identified Cause)

Sorethroat
Ageusia (Loss Of Tastel, W/O Any Identified Cause)

Coryza
Others

Others
Comorbidities (Check all that apply if present)

None
Gastrointestinal

Hypertension
Genito-Urinary.

Diabetes
Neurological Disease

Heart Disease
Cancer

Lung Disease
Others

Others

Pregnant? High Risk Pregnancy? Was diagnosed to have Severe Acute

Respiratory Illness?

YES
LMP
YES

NO
YES

NO

NO

N/A

Chest Imaging Findings suggestive of COVID-19

 Date Done Chest imaging done Results

MM/DD/YYYY
Chest Radiography
Normal

Chest CT
Pending

Lung Ultrasound
Chest Radiography: Hazy Opacities, Often Rounded In Morphology, With
Peripheral And Lower Lung Dist.

None

Chest CT : Multiple Bilateral Ground Glass Opacities, Often Rounded In
Morphology, W/ Peripheral & Lower Lung Dist

Lung Ultrasound: Thickened Pleural Lines, B Lines, Consolidativepatterns
With Or Without Air Bronchograms

Other Findings, Specify pls specify

       2.7 Laboratory Information

Have you tested positive using RT-PCR before? *

YES Date of Specimen Collection, Laboratory No. of previous RT-PCR swabs
NO
When? done
Philippine Red Cross - Negros
09/03/2021 1

Date collected Date Released Laboratory Type of test* Results*

09/15/2022 MM/DD/YYYY Molecular Biology

RT-PCR (OPS)
Pending

RT-PCR (NPS)
Negative

RT-PCR (OPS And NPS)
Positive

Antigen: Reason
Equivocal

Others:

Brand Of Kit

Antibody Test

Others:

Date collected Date Released Laboratory Type of test* Results*

MM/DD/YYYY MM/DD/YYYY Laboratory Name

RT-PCR (OPS)
Pending

RT-PCR (NPS)
Negative

RT-PCR (OPS And NPS)
Positive

Antigen: Reason
Equivocal

Others:

Brand Of Kit

Antibody Test

Others:

       2.9 Outcome/Condition at Time of Report *

Active (Currently Admitted Or In Isolation/Quarantine)
Recovered, Date Of Recovery MM/DD/YYYY

Died, Date Of Death * MM/DD/YYYY
In case of Death kindly indicate
Cause of Death*

Immediate Cause Antecedent Cause Underlying Cause

Other significant Condition contributing to

Death

Part 3. Contact Tracing: Exposure and Travel History

 History of exposure to known probable and/or confirmed COVID-19 case
YES Yes, Date of LAST
14 days before the onset of signs and symptoms? OR if Asymptomatic, 14 Contact *
days before swabbiing or specimen collection? *
MM/DD/YYYY

NO

Unknown

Has the patient been in a place with a known COVID-19 transmission 14

Yes, International
Yes, Local

days before the onset of signs and symptoms? OR If Asymptomatic, 14

NO
Unknown Exposure
days before swabbing or specimen collection? *

If International Travel, Country Of Origin

Inclusive Travel Dates:

From: MM/DD/YYYY To: MM/DD/YYYY

With Ongoing COVID-19 Community Transmission?

Yes

No
Airline/Sea Vessel Flight/Vessel Number Date Of Departure Date Of Arrival In PH

MM/DD/YYYY MM/DD/YYYY

       If Local Travel, specify travel places (Check all that apply, provide name of facility, address, and inclusive travel dates in MM/DD/YYYY)

Place Visited Name Of Place Address (Region, Inclusive Travel Inclusive Travel With Ongoing
Province, Dates From: Dates To: COVID-19
Municipality/City) Community
Transmission?
Health Facility MM/DD/YYYY MM/DD/YYYY
YES

NO

Closed Settings MM/DD/YYYY MM/DD/YYYY

YES

NO

School MM/DD/YYYY MM/DD/YYYY

YES

NO

Workplace MM/DD/YYYY MM/DD/YYYY

YES

NO

Market MM/DD/YYYY MM/DD/YYYY

YES

NO

Social Gathering MM/DD/YYYY MM/DD/YYYY

YES

NO

Others MM/DD/YYYY MM/DD/YYYY

YES

NO

Transport Service, Specify The Following :

Airline / Sea Vessel / BusFlight / Vessel / Bus No. Place Of Origin Departure Date Destination Date Of Arrival
Line / Train
MM/DD/YYYY MM/DD/YYYY

Airline / Sea Vessel / BusFlight / Vessel / Bus No. Place Of Origin Departure Date Destination Date Of Arrival

Line / Train

MM/DD/YYYY MM/DD/YYYY

-If symptomatic, provide names and contact numbers of persons who were with the patient two days prior to onset of illness until this date

-If asymptomatic, provide names and contact numbers of persons who were with the patient on the day specimen was submitted for testing until this date

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By filling up this form, I confirm that:

I have been informed that Riverside Medical Center, Inc. is undertaking these measures to ensure that
the well-being and protection of everyone, myself included, is prioritized. I understand that data about
COVID-19 is constantly changing and despite the diligent efforts of Riverside Medical Center, Inc. to
minimize transmission, there is still a risk of acquiring the infection.

The information I have provided are TRUE and CORRECT and I am aware that any untruthful
statements I make may have serious consequences on public health and safety for which I may be held
liable under the law.

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