• DATA COLLECTION FORM

  • Date Accomplished*
     - -

  • General Details

  • Gender*
  • Date of specimen collection
     - -
  • Date of laboratoryconfirmation (Date of release of results)
     - -
  • Date of admission (If applicable)
     - -
  • Date of Discharge
     - -
  • Date of demise (If applicable)
     - -
  • Estimated date of onset of first symptom (MM/DD/YYYY)
     - -
  • Signs and symptoms

  • Medical History and co-morbid illnesses

  • Pregnancy
  • Trimester ofpregnancy

  • Personal and Social History


  • Has the patient travelled internationally in the 14 days prior to symptom onset?
  • Has the patient traveled locally in the 14 days prior to symptom onset?
  • If NOT from San Juan, any travel to San Juan or Greenhills?
  • Has the patient visited any health care facilities in the 14 days prior to symptom onset?
  • Has the patient had close contact with a person with acute respiratory infection (ARI) in the 14 days prior to symptom onset?
  • ARI close contact in health care setting
  • ARI close contact in family setting
  • ARI close contact in workplace
  • Date of exposure to close contact with ARI
     - -
  • Has the patient had contact with probable or confirmed cases?
  • Date of exposure to probable or confirmed case
     - -
  • Did the patient visit any live animal markets?
  • Date of exposure to live animals
     - -
  • Date of exposure to probable or confirmed case (MM/DD/YYYY)
     - -
  • Did the patient visit any live animal markets?
  • Date of exposure tolive animals (MM/DD/YYYY)
     - -
  • Rows

  • Imaging and other diagnostics during admission

  • Chestx-ray done?
  • Date of first X-ray
     - -
  • Initial CXR findings

  • Date of second X-ray
     - -
  • Findings

  • Date of third X-ray
     - -
  • Findings

  • Chest CT scan done?
  • Date of first CT scan
     - -
  • Initial CT scanfindings


  • Date of second CT scan
     - -
  • Findings of second CT scan

  • Chest ultrasound done?
  • Date of chest ultrasound
     - -
  • Initial chest ultrasound findings

  • ECG done?
  • Date of ECG
     - -
  • ECG findings

  • 2D Echo done?
  • Date of 2D Echo
     - -
  • Date of others
     - -

  • Medications during admission

    • INVESTIGATIONAL DRUGS 
    • OTHER ANTI-INFECTIVES 

  • Course in the wards

  • Rows
  • Final Diagnosis
  • COMPLICATIONS
  • Cause of death
  •  
  • Should be Empty: