Philippine Integrated Disease

Surveillance and Response

Case Investigation Form
Severe Acute Respiratory Infection w/ Novel Coronavirus (SARIC)
Instructions to Attending Physician: Fill this form for each new patient admitted to the SARS wards. Fax duly filled up form to NEC 743-
6076 / 731-3726 Revised 10/04/2012
Disease Reporting Unit: Name of Investigator: Date of Interview:

1. Patient Profile
Last Name First Name Middle Name Birthday: Age Sex

Occupation Civil Status Nationality Educational Attainment

2. Philippine Residence
House No./Lot/Blk/Bldg Street District Municipality/City

Province Region Home Phone No Cellphone No.

3. History of travel/visit/work in other

( ) Yes ( ) No Date of Arrival in Philippine:
countries within last 14 days:
Time of departure
Airlines/Sea vessel Port of Entry: Flight Number

4. Overseas Residence
House No./Bldg Name Street City/Municipality District

Province/State Country Home Phone No. Cellphone No.

5. Overseas Employment Address

Employers Name: Occupation Place of Work:

House No./Bldg Name Street City/Municipality District

Province/State Country Office Phone No. Cellphone No.

6. Countries Visited / Traveled / Worked in During Last 14 Days (Please check)

China ( ) Hongkong ( ) Singapore ( ) Vietnam ( ) Taiwan ( )

USA ( ) Canada ( ) Middle East: ( ) Others, specify: _____________________________

7. History of Exposure to
( ) Yes ( ) No ( ) Unknown Date of Last Contact with Known SARIC Case:
Known SARIC Case
8. Signs & Symptoms Date of Onset of Illness
Shortness / difficulty of
Fever ________ oC / oF Cough ( ) Body weakness ( ) Muscle ache ( )
breathing ( )

Diarrhea ( ) Rash ( ) Others, specify

MM DD YYYY
9. Radiography Chest XRAY done? ( ) Yes ( ) No If yes, when?
Other Radiologic Findings:
CXR Results: Pneumonia ( ) Yes ( ) No ( ) Pending
Other Laboratory Tests/Results:

10. Clinical Status at

Inpatient ( ) Outpatient ( ) Dead ( ) Discharged ( ) Unknown ( )
Time of Report

Hospitalized? ( ) Yes ( ) No Date of admission / Consultation

Is patient currently on
( ) Yes ( ) No Was patient previously on mechanical ventilator? ( ) Yes ( ) No
mechanical ventilator?
Name of Informant: (if patient not available) Relationship: Phone No.

Date of Discharge Final Diagnosis Condition on Discharge: ( ) Died ( ) Improved ( ) Recovered

( ) Transferred ( ) Absconded

Case
Case Definition
Definition
Investigation -- aa person
0 0
Patient
Patient Under
Under Investigation person with
with acute
acute respiratory
respiratory infection,
infection, with
with fever 380C,
fever (( >> 38 100.40F)
C, 100.4 F) and
and cough,
cough, and
and suspicion
suspicion of
of parenchymal
parenchymal disease
disease
(e.g.
(e.g. pneumonia
pneumonia or or Acute
Acute respiratory
respiratory distress
distress syndrome
syndrome based
based on
on clinical
clinical or
or radiological
radiological evidence
evidence of of consolidation
consolidation andand history
history of
of travel
travel to
to or
or residence
residence inin an
an
area
area where
where infection
infection with
with novel
novel coronavirus
coronavirus has
has been
been reported
reported oror transmission
transmission could
could have
have occurred
occurred andand not
not already
already explained
explained by
by any
any other
other infection
infection or
or
etiology including all clinically indicated test for acquired community pneumonia
etiology including all clinically indicated test for acquired community pneumonia
Probable
Probable Severe
Severe acuteacute respiratory
respiratory infection
infection w/w/ coronavirus
coronavirus –– aa person person fitting
fitting the
the case
case definition
definition above
above and
and close
close contact
contact with
with aa laboratory
laboratory
confirmed
confirmed case
case and
and notnot already
already explained
explained by
by any
any other
other infection
infection or
or etiology
etiology including
including all
all clinically
clinically indicated
indicated test
test for
for acquired
acquired community
community pneumonia
pneumonia
Confirmed Severe acute respiratory infection w/ novel coronavirus
Confirmed Severe acute respiratory infection w/ novel coronavirus – a suspect case that is laboratory confirmed of infection with the
– a suspect case that is laboratory confirmed of infection with the novel
novel
coronavirus
coronavirus