COVID PATIENT INFORMATION CHECKLIST CT# ___________ LP#__________

NAME: MAGANGAN SUSANA LATORRE

FAMILY FIRST MIDDLE NAME

AGE: 55 SEX: ( ) MALE (/ ) FEMALE BIRTHDATE: 05/18/1965 NATIONALITY: FILIPINO

CONTACT #’S: 09532589600 RELIGION: ROMAN CATHOLIC

ADDRESS: P5,QUILING ROXAS ISABELA

NUMBER STREET SUBD. BARANGAY

CIVIL STATUS: ( / ) SINGLE ( )MARRIED ( ) WIDOW

RISK FACTORS: ( ) ELDERLY ( ) HYPERTENSION ( ) DIABETES ( ) COPD ( ) ASTHMA ( ) PREGNANT

( / ) OTHERS: DEAF --MUTE OCCUPATION:

WORK ADDRESS: CONTACT #: _____________

DATE AND PLACE OF SWAB TEST: ( ) OPD/ER:

( ) ADMITTED AT:

( / ) OTHERS RHU ROXAS (04/26/21)

HISTORY OF EXPOSURE : ( ) WORK RELATED (MEDICAL)

( ) WORK RELATED (NON MEDICAL)
( ) CONTACT OF CONFIRMED CASE:
Household: 6

Work Place:

( ) WITH HISTORY OF TRAVEL

( ) UNKNOWN
( ) MEETINGS/ GATHERINGS (specify):

DATE OF RELEASED OF RESULTS: ( ) ADMITTED AT HOSPITAL

(/ )
RESIDENCE VIA PHONE CALL

( ) AFTER DISCHARGE

( ) EXPIRED

HEALTH STATUS UPON INTERVIEW: ( / ) ASYMPTOMATIC ( ) RECOVERED ( ) EXPIRED

( ) SYMPTOMS

( ) DATE OF ONSET OF SYMPTOMS

( ) EXPIRED, DATE AND TIME OF DEATH

DATE AND TIME OF CREMATION:

DATE AND TIME OF BURIAL:

REASON FOR BURIAL:

NUMBER OF CONTACTS: ( ) HOUSEHOLD

( ) GENERAL CONTACTS

IS THERE A HIGH-RISK HOUSEHOLD MEMBER (ELDERLY/ NONSENIOR BUT WITH COMORBIDITY/ PREGNANT/
IMMUNOCOMPROMISED) IN THE HOUSE? (Y/ N)
DOES THE PATIENT SHARE CR WITH HOUSEHOLD OR GOES OUT OF ROOM TO USE CR? ( Y/N )
DOES THE PATIENT LIVE IN AN URBAN POOR AREA? ( Y/N )
WILL THE HOUSEHOLD MEMBERS HAVE DIFFICULTY MAINTAINING PREVENTIVE MEASURES AT HOME? ( Y/N )
(THIS QUICK ASSESSMENT IS FOR PRIORITIZATION PURPOSES. ALL PATIENTS ARE FOR ISOLATION FACILITY; NO HOME
ISOLATION POLICY IS BEING IMPLEMENTED)

STATUS OF CONTACTS: ( ) ALL ASYMPTOMATIC

( ) SYMPTOMATIC: (NAME AND SYMPTOMS)

DISPOSITION: ( ) HOSPITAL ADMISSION:

(X) QUARANTINE FACILITY:

( ) HOME QUARANTINE:

PREVENTIVE MEASURES LIKE SOCIAL DISTANCING, USE OF MASK AT HOME, HANDWASHING/USE OF ALCOHOL AND
STRICT HOME QUARANTINE HAVE BEEN ADVISED TO PATIENT AND ALL CONTACTS? ( Y/N )

INTERVIEWED BY:
DATE OF INTERVIEW:

PLEASE FILL UP SYMPTOMS AND RISK FACTORS BOX

LAST NAME: DATE:

FIRST NAME: CONTACT NUMBER:

MIDDLE NAME: OCCUPATION:

AGE / SEX: WORK ADDRESS:

SWAB DATE: REASON FOR SWAB:

DATE OF ONSET OF SYMPTOMS: WORK PHONE NUMBER:

DATE OF RESOLUTION OF SYMPTOMS; WORK CONTACT PERSON:

SIGNS & SYMPTOMS:

(Please include SPECIFIC whereabouts 1 week from onset of symptoms or date of specimen collection of positive result (if
asymptomatic) until 14 days or until the day of contact tracing. PLEASE INCLUDE ALL CONTACTS INCLUDING THE GENERAL
CONTACTS / CASUAL CONTACTS EVEN IF ONLY THE FIRST NAME/ALIAS IS KNOWN.
INCLUDE SPECIFIC PLACES WHERE THE PATIENT WENT

REVIEW OF WHEREABOUTS AND CONTACTS:

DATE AND APPROXIMATE TIME LOCATION & ACTIVITY PERSONS ENCOUNTERED
SPECIAL ENDORSEMENTS: