Notification Form for Viral Haemorrhagic Fevers ‫ﻪ‬:‫ﻔ‬87‫ ﻧ‬5‫ﺎە ﺣ‬32‫اﺳﺘﻤﺎرة )ﻼغ ﻋﻦ ﺣﺎﻟﺔ اﺷ‬

Demographics - ‫اﻟﺑﯾﺎﻧﺎت اﻟﺷﺧﺻﯾﺔ‬

Name: ‫اﻻﺳم‬
Medical Record No.: ‫رﻗم اﻟﻣﻠف‬
Nationality: ‫اﻟﺟﻧﺳﯾﺔ‬
Sex: M / F (Pregnancy): Y \ N ‫اﻟﺟﻧس‬
Civil card number/Iqama number: ‫اﻟﺳﺟل اﻟﻣدﻧﻲ أو رﻗم اﻹﻗﺎﻣﺔ‬
Address: district: :‫ اﻟﺣﻲ‬:‫اﻟﻌﻧوان‬
Street: :‫اﻟﺷﺎرع‬
A milestone near the home: :‫ﻣﻌﻠم ﺑﺎرز ﻗرب اﻟﺳﻛن‬
Home Office/ Tel: :‫ﻋﻣل‬/ ‫ ﻣﻧزل‬:‫ھﺎﺗف‬
Mobile: :‫ﺟوال‬
Relevant phone number: :‫رﻗم ﺟوال أﺣد اﻷﻗﺎرب‬
Occupation address :‫ﻋﻧوان اﻟﻌﻣل‬
Date of onset of patient’s presenting illness: :‫ﺗﺎرﯾﺦ ﺑداﯾﺔ ظﮭور اﻷﻋراض‬
Date of presentation to the hospital: :‫ﺗﺎرﯾﺦ ﻣراﺟﻌﺔ اﻟﻣﺳﺗﺷﻔﻰ‬
Is the patient hospitalized Yes No :‫ھل ﺗم ﺗﻧوﯾم اﻟﻣرﯾض‬
Date of admission: :‫ﺗﺎرﯾﺦ اﻟدﺧول‬
Date of patient discharge :‫ﺗﺎرﯾﺦ اﻟﺧروج‬
Vital signs at presentation ‫اﻟﻌﻼﻣﺎت اﻟﺣﯾوﯾﺔ‬
T: P: BP: R: ‫اﻟﺗﻧﻔس‬ :‫اﻟﺿﻐط‬ :‫اﻟﻧﺑض‬ :‫اﻟﺣرارة‬

Manifestation Y N U Comments
Fever (> 38.0 OC) Highest temp:
Skin rash Describe the rash:
Respiratory distress Y N U
Chills Anorexia
General Manifest.

GIT Manifest.

Malaise Nausea
Headache Vomiting
Retro-ocular pain Diarrhea
Myalgia Abdominal pain
Arthralgia Jaundice
Backache Pleural effusion
Leakey
Bl. V.

Epistaxis Ascites
Gingival bleeding Peripheral edema

Bleeding from puncture sites Vertigo

CNS manifestations

Petechiae Confusion
Ecchymosis Disorientation
Purpura Hallucinations
Hematemesis Coma
Bleeding Manifestations

Melena Convulsions
Fresh blood per rectum Neck stiffness
Menorrhagia Photophobia
Positive tourniquet test Hemiparesis
Other bleeding sites
Shock
Visual loss
Persistent vomiting
Other warning signs

Abortion:
symptoms

Severe abdominal pain

Severe lethargy

Enlarged liver >2cm

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Notification Form for Viral Haemorrhagic Fevers ‫ﻪ‬:‫ﻔ‬87‫ ﻧ‬5‫ﺎە ﺣ‬32‫اﺳﺘﻤﺎرة )ﻼغ ﻋﻦ ﺣﺎﻟﺔ اﺷ‬

3- Laboratory investigations (the most abnormal value)

Lab test Result Lab test Result Lab test Result Lab test Result
WBC Total protein AsT LDH
Hemoglobin Albumin AlT CPK
Hematochrit PT (INR) AlP Creatinine
Platelets PTT T. bilirubin Other

4- Specific Laboratory Test: ‫ ﻓﺣوﺻﺎت ﻣﺧﺑرﯾﮫ ﻧوﻋﯾﮫ‬- 4

Sample Sample Date Results (Positive, Negative, or Not done)
serial no. no: ‫ﺗ ﺎر ﯾﺦ‬
Disease RDT Igm IgG Culture PCR Date of
(1st, 2nd, ‫ر ﻗ م اﻟ ﻌ ﯾ ﻧ ﺔ‬ ‫ﺳﺣب‬ Antigen
3rd) ‫اﻟﻌ ﯾ ﻧﺔ‬ result
DENGUE
F
Rift Valley
F
AlKhurma
F
CCHF
Others
Regional Lab sending Date
‫ﺗﺎرﯾﺦ إرﺳﺎل اﻟﻌﯾﻧﺔ اﻟﻰ اﻟﻣﺧﺗﺑر اﻻﻗﻠﯾﻣﻲ‬

5- Contact with suspected or confirmed case ‫ ﻣﺧﺎﻟطﺔ ﺣﺎﻟﺔ ﻣﺷﺗﺑﮭﺔ أو ﻣؤﻛدة‬-5

Contact with a patient has the similar symptoms or disease ‫ھل ﺗﻣت ﻣﺧﺎﻟطﺔ ﻣرﯾض ﻟدﯾﮫ ﻧﻔس اﻷﻋراض‬
Yes No

6- Final Patient Status ‫اﻟﺣﺎﻟﺔ اﻟﻧﮭﺎﺋﯾﺔ ﻟﻠﻣرﯾض‬-6

ICU admission Date of ICU Admission Date of ICU discharge

Recovered Transferred to other hospital Died

Name of person filling out this form: --------------------------------- Job Title ---------------------------

Workplace: ----------------------------------------------------- Phone number-----------------------------

Name of attending physician ------------------------------ Phone number: ---------------------------

Date of filling out the form: / /

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