Title Page
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Case ID
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Name of Patient
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Name of Investigator
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Disease Reporting Unit
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Date of Interview
Case Investigation Form
Patient Profile
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Last Name
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First Name
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Middle Name
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Birthday
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Age
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Sex
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Occupation
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Civil Status
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Nationality
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Passport Number
Residence
Permanent Address
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House No./Lot/Bldg
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Street/Barangay
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Municipality/City
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Province
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Region
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Home Phone No.
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Cellphone No.
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E-mail address
Current Address
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House No./Lot/Bldg
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Street/Barangay
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Municipality/City
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Province
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Region
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Home Phone No.
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Cellphone No.
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Other E-mail address
Address Outside the Philippines (for Overseas Filipino Workers and Individuals with Residence Outside the Philippines)
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Employer’s Name
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Occupation
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Place of Work
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House No./Bldg. Name
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Street
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City/Municipality
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Province
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Country
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Office Phone No
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Cellphone No.
Travel History
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History of travel/visit/work in other countries with a known COVID-19<br>transmission 14 days before the onset of your signs and symptoms:
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Port (Country) of exit
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Airline/Sea vessel
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Flight/Vessel Number
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Date of Departure
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Date of arrival in Philippines:
Exposure History
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History of Exposure to Known COVID-19 Case 14 days before the onset of signs and symptoms
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Date of Contact with Known COVID-19 Case
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Relationship
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Have you been in a place with a known COVID-19 transmission 14 days before the onset of signs and symptoms:
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Place:
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Others
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Date when you have been in that place:
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List the names of persons who were with you during this (these) occasion(s) and their contact numbers:
Names
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Name
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Contact Number
Clinical Information
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Disposition at Time of Report
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Date of Onset of Illness
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Date of Admission/Consultation
Symptoms
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Fever
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If answered yes to Fever, what is the temperature in in °C?
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Cough
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Sore throat
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Colds
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Shortness/difficulty of breathing
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Other signs of symptoms
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Is there any history of other illness?
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Specify
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Chest X-Ray done?
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When?
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Are you pregnant?
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LMP
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Assessed as High Risk?
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CXR Results: Pneumonia
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Other Radiologic Findings
Specimen Information
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Specimen
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if YES, Date Collected
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Date sent to RITM
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Date received in RITM
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Virus Isolation Result
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PCR Result
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Oropharyngeal/ Nasopharyngeal swab
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if YES, Date Collected
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Date sent to RITM
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Date received in RITM
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Virus Isolation Result
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PCR Result
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Others
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Describe
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if YES, Date Collected
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Date sent to RITM
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Date received in RITM
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Virus Isolation Result
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PCR Result
Classification
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Suspect Case
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Probable Case
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Confirmed Case
Outcome
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Date of Discharge
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Condition on Discharge
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Name of Informant (if patient is not available)
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Relationship with patient
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Phone No.
