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

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 APPENDIX 3

D. Epidemiological Risk Assessment

Within 14 days before onset of the illness, did you:(Please tick the relevant answer)
1. have close contact2 with a confirmed or probable (hospitalized or under quarantine)
suspected COVID-19 infection case in 1affected countries?
2. Travel to or reside in country with known transmission of COVID-19 infection outbreak?
(name the country: ______________________________________)
3. Any additional information:
___________________________________________________________

1
Affected Countries as for 26 February 2020:
• China (including Hong Kong, Macau and Taiwan)
• South Korea
• Japan
• Italy
• Iran

2
Close contact is defined as:
a) Health care associated exposure without appropriate PPE (including providing direct
care for COVID-19 patients, working with health care workers infected with COVID-19,
visiting patients or staying in the same close environment of a COVID-19 patient).
b) Working together in close proximity or sharing the same classroom environment with a
with COVID-19 patient
c) Traveling together with COVID-19 patient in any kind of conveyance
d) Living in the same household as a COVID-19 patient

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