Philippine Integrated Disease
Surveillance and Response
Case Investigation Form
Coronavirus Disease (COVID-19)
Disease Reporting Unit/Hospital: Name of Investigator: Date of Interview:
1. Patient Profile
Last Name First Name Middle Name BDATE Age Sex: ( ) Male
GAMMAD VENESSA JOY TAGUBA 02 SEPT 1985 34
( X ) Fem.
Occupation Civil Status Nationality Passport No.
MILITARY PROFESSOR SINGLE FILIPINO N/A
2. Philippine Residence
2.1 Permanent Address
House # /Lot /Bldg. Street / Barangay Municipality / City. Province
CORNER TAFT LEGASPI ST TUGUEGARAO CITY
REGION Home Phone # CP # Email
2 N/A 0915-111-2097 venessajoygammad@g
mail.com
2.2 Current Address
House No./Lot/Bldg. Street/Barangay Municipality/City. Province
1123 GUADALUPE VIEJO JP RIZAL ST MAKATI CITY
Region. Home Phone No. Work Phone No. Other Email address
NCR N/A (02) 8911 8142 [email protected]
3. Address Outside the Philippines (for Overseas Filipino Workers and Individuals with Residence Outside the Philippines)
Employer's Name: Occupation Place of Work:
N/A N/A N/A
House No./Bldg. Name Street City/Municipality Province
N/A N/A N/A N/A
Country:N/A Office Phone No.:N/A Cellphone No.:N/A
4. Travel History
History of travel/visit/work in other countries with a known COVID-19 ( ) Yes Port (Country) of exit:
transmission 14 days before the onset of your signs and symptoms: (X ) No No N/A
Airline/Sea vessel: Flight/Vessel Number: Date of Departure (mm/dd/yyyy) Date of Arrival in Philippines:
N/A N/A N/A N/A
5. Exposure History
History of Exposure to Known COVID-19 Case 14 days before the onset ( ) Yes If yes: Date of Contact with Known COVID-19 Case
of signs and symptoms: (X ) No (mm/dd/yyyy):N/A
( ) Unknown
Have you been in a place with a known ( ) Yes If yes: Place: ( ) Workplace ( ) Health facility
COVID-19 transmission 14 days before the (X ) No N/A( ) Social gathering ( ) Religious gathering
onset of signs and symptoms: ( ) Unknown ( ) Others: specify type:
Date when you have been in that place:
Name of the place:
List the names of persons who were with you during this (these) Name Contact number
occasion(s) and their contact numbers: N/A
Use the back part of this sheet when needed
6. Clinical Information
Disposition at Time of Report N/A ( ) Inpatient ( ) Outpatient ( ) Discharged ( ) Died ( ) Unknown
Date Of Onset of Illness (mm/dd/yyyy): N/A Date of Admission/Consultation (mm/dd/yyyy) N/A
Fever °C ( ) Cough ( ) Sore throat ( ) Colds ( ) Shortness/difficulty of breathing
Other signs/symptoms, specify N/A Is there any history of other illness? ( ) Yes (X ) No
If YES, specify:N/A
Chest X-ray done? ( ) Yes (X ) No Are you pregnant? ( ) Yes (X ) No
If yes, when?N/A LMP Assessed as High Risk? ( ) Yes ( X) No
Cxr Results: N/A ( ) Yes ( ) No ( ) Pending Other Radiologic Findings:N/S
7. Specimen Information
If YES, Date Collected Date sent Date received in RITM PCR
Specimen Collected to RITM Virus Isolation Result
(mm/dd/yyyy) (HOUR : MINS) (mm/dd/yyyy) (to be filled up by RITM) Result
/
( ) Serum / / / / /
( ) Oropharyngeal/ /
/ / / / /
Nasopharyngeal
/
( ) Others / / / / /
8. Classification
( ) Suspect Case ( ) Probable Case ( ) Confirmed Case
9. Outcome
Date of Discharge (mm/dd/yyyy): Condition on Discharge:
( ) Improved ( ) Recovered ( ) Transferred ( ) Absconded ( ) Died
Name of Informant: (if patient not available) Relationship: Phone No.
