APPENDIX 3

CLERKING SHEET TEMPLATE AT MALAYSIA POINT OF ENTRY

Date:_________________ Interviewer’s Name : _________________________________________

A. Patient’s Details
Patient’s Name : __________________________________________________________________
I/C / Passport No. : _________________________ Age : _________________ Gender : M / F
Address in country of origin :
_________________________________________________________________________________
Address in Malaysia :________________________________________________________________
Contact number in Malaysia: ______________
Nationality : Malaysian / Non – Malaysian ___________________________________________
Next of Kin (Name & Contact) : _______________________________________________________

B. Travel History
No. Country/State/Province Duration of Stay Name of Airline, Flight No.
Visited From (dd/mm/yr) To (dd/mm/yr) and Seat Number:
1.
2.
3.
Date of return to Malaysia: Entry Point:

C. Sign and Symptoms

i. Symptoms ii. Vital Sign

Date of Onset: Temperature:
Fever: *Blood Pressure (mmHg)
Cough: *Pulse Rate (/ min):
Breathlessness: *Respiratory Rate (/min):
*SpO2 (if available)
Other symptoms: *Other vitals:

iii. *Respiratory Findings

iv. *Other relevant clinical

history and examination

* to be filled by paramedic or doctor

D. Epidemiological Risk Assessment
Within 14 days before onset of the illness, did you:(Please tick the relevant answer)
1. have close contact1 with a confirmed or probable (hospitalized or under quarantine)
suspected 2019 novel coronavirus (2019 - nCoV) Infection case in China?
2. Travel to either China or country with known transmission of recent 2019-nCoV Infection
outbreak?
(name the country: ______________________________________)
3. have history of visiting wet markets / seafood markets in Wuhan, China
If Yes, please specify :________________________________________
4. Any additional information :
___________________________________________________________

1
Close contact is defined as:
a) Health care associated exposure, including providing direct care for 2019-nCoV
patients, working with health care workers infected with 2019 -nCoV, visiting patients
or staying in the same close environment of a 2019-nCoV patient.
b) Working together in close proximity or sharing the same classroom environment with a
with 2019-nCoV patient
c) Traveling together with 2019-nCoV patient in any kind of conveyance
d) In the same household as a 2019-nCoV patient