Manila Doctors Hospital
Task Force SARS Screening
Questionnaire Form
Patient
Name: __________________ Age: ___ Sex: ___Occupation:_________
Address:
______________________ Tel No:
____________________
______________________ Cellphone
No: ______________
Brought
by: ____________________ Relation to Patient: __________________
Address:
______________________ Tel No:
____________________
______________________ Cellphone
No: ______________
I.At
ENTRY (OPD, Doctors Clinic, ER Entrance)
Do you have any of the following? ____ YES
____NO
____ Fever ____ Shortness of
Breath
____ Cough or Colds ____ Difficulty of Breathing
If YES, to any of the above, proceed
to No. 2. If NO, direct patient to ER.
2.
TRIAGE
2.1
Travel History
Did you travel OUTSIDE the country within 14 days
from the onset of respiratory signs and symptoms? ____ YES ____NO
IF yes, where?
____ China ____
Hanoi, Vietnam
____ HongKong ____ Toronto, Canada
____ Guangdong ____ Singapore
____ Taiwan ____ Others,
specify
2.2
Exposure History
2.2.1
Have you had close contact with any household member with respiratory illness
who traveled to the abovementioned places?
____YES ____NO
2.2.2
Have you have close contact with a friend or business partner with respiratory
illness who traveled to the abovementioned places? ____YES ____NO
2.2.3
Have you taken cared of or have contact with respiratory secretions and body
fluids of diagnosed case or suspect of SARS?
____YES ____NO
2.3
ASSESSMENT
____ Suspect SARS
____ Probable SARS
____ Not SARS
2.4
Disposition
____ Discharge with advise
____ Transferred to ---- RITM ---- San
Lazaro Hospital
____ Admitted at 11F
Signature
over printed name
Triage
Intern/ERO
_____________________________________________________________________________
SARS
SUSPECT:
Person presenting after February 1,
2003 with fever > 38 C, respiratory symptoms and (+) travel history within14
days of onset of symptoms
CLOSE
CONTACT:
Having cared for, lived with or have
direct contact with respiratory secretions and/or body fluids of a SARS suspect