Federal Ministry of Health

Malaria Identification and Counseling Form

Name: ___________________________________Sex: ______DOB: ___/___/___Age:_____Individual ID:______________

Date of Visit
The signs and symptoms of Malaria
____/____/____ ____/____/____ ____/____/____ ____/____/____ ____/____/____
1. Chilling or recent history of convulsions?? (Y/N)

2. Altered consciousness? (Y/N)

3. Fatigue or Tiredness? (Y/N)

4. High temperature/Fever? (Y/N)

5. Vomiting? (Y/N)

6. Jaundice? (Y/N)

7. Other (Specify)? (Y/N)

Result of assessment of risk factors interpretation:

 If the answer is YES to any of the questions above, indicate the person as
risk for Malaria and REFER the client to HC
 If the answer is NO to all of the questions above, reassess the client with
counseling

8. Conduct blood test using RDT and/or treat as per the

national guideline if applicable
Counseling service provided on:
1. Adherence
2. on ITN Utilization, IRS, Environmental Management and other
interventions
3. Early Health Seeking Behavior
4. Other……………….

Emergency care?(Y/N)
Referral service provided? (Y/N)
Follow-up? (Y/N)