COVID-19 RT-PCR Online Transaction

1. Basic Information

Patient Profile
*
*

Philippine Residence

2.1.Permanent Address
2.2.Current Address
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2. DOH CIF


Philippine Integrated Disease

Surveillance and Response

Case Investigation Form

Coronavirus Disease (COVID-19)

Disease Reporting Unit/Hospital:

Name of Investigator:

Date of Interview: (mm/dd/yyyy)
1. Patient Profile

Last Name:

First Name:

Middle Name:

Birthday: (mm/dd/yyyy)

Age:
Sex
Male
Female

Occupation:

Civil Status:

Nationality:

Passport:
2. Philippine Residence
2.1 Permanent Address

House No/Lot/Bldg.:

Street/Barangay:

Municipality/City:

Province:

Region:

Home Phone No.:

Cellphone No.:

Email Address:
2.2 Current Address

House No/Lot/Bldg.:

Street/Barangay:

Municipality/City:

Province:

Region:

Home Phone No.:

Cellphone No.:

Email Address:
3. Address Outside the Philippines (for Overseas Filipino Workers and Individuals with Residence Outside the Philippines)

Employer's Name:

Occupation:

Place of Work:

House No./Bldg. Name:

Street:

City/Municipality:

Province:

Country:

Office Phone No.:

Cellphone No.:
4. Travel History

History of travel/visit/work in other countries with a known COVID-19 transmission 14 days before the onset of your signs and symptoms:
Yes
No

Port (Country) of exit

Airline/Sea Vessel:

Flight/Vessel Number:

Date of Departure (mm/dd/yyyy)

Date of arrival in Philippines: (mmm/dd/yyyy)
5. Exposure History

History of Exposure to Known COVID-19 Case 14 days before the onset of signs and symptomes:
Yes
No
Unknown

If yes: Date of Contact with known COVID-19 Case (mm/dd/yyyy)

Have you been in a place with a known COVID-19 transmission 14 days before the onset of signs and symptoms:
Yes
No
Unknown

If YES: Place:
Workplace
Social Gathering
Others, specify type:
Health facility
Religious gathering
Date when you have been in that place:

List the names of persons who were with you during this (these) occasion(s) and their contact numbers:

Use the back part of this sheet when needed

Name

Contact Number

6. Clinical Information

Disposition at Time of Report
Inpatient
Outpatient
Discharged
Died
Unknown

Date of Onset of Illness (mm/dd/yyyy):

Date of Admission/Consultation (mm/dd/yyyy:)

Fever: °C
Cough
Sore throat
Colds
Shortness/difficulty of breathing

Other signs/symptoms, specify:

Is there any history of other illness?

If YES, specify:

Yes
No

Chest X-ray done?

If YES, when? :

Yes
No

Are you pregnant?

Yes
No

LMP:

Assessed as High Risk?
Yes
No

CXR Result: Pneumonia
Yes
No
Pending

Other Radiologic Findings:

7. Specimen Information

Specimen Collected

If YES, Date Collected (mm/dd/yyyy)

Date sent to RITM (mm/dd/yyyy)

Date received in RITM (to be filled up by RITM)

Virus Isolation Result

PCR Result
Serum

Oropharngeal/ asopharyngealswab

Others

8. Classification
Suspect Case
Probable Case
Confirmed Case
9. Outcome

Condition on Discharge:

Date of Discharge (mm/dd/yyyy):

Improved
Recovered
Transfered
Absconded
Died

Name of information: (if patient not available)

Relationship:

Phone No.:

3. PHMC-LP SARS-CoV-2 REQUEST FORM


Form No. 3 PHMC-LP SARS-CoV-2 REQUEST FORM

Modular Diagnostic Laboratory

IMPORTANT: Please complete requested details below to avoid delays in processing.

PATIENT/SOURCE INFORMATION
Last Name:
First Name: Middle Name:
Address:
Date of Birth: Age/Gender:
Clinical Impression: Date of onset illness:
Requestd by (AP):
Nurse-in-Charge:
Date/Time Requested:
Inpatient
Outpatient
SPECIMEN INFORMATION
Specimen Type All specimen submitted should be treated as infectious.
All specimen must be sent in accordance with Cat. B transport guidance
Nasopharyngeal swab (NPS)
Oropharygeal swab (OPS)
Nasopharyngeal swab (NPS)/ Oropharygeal swab (OPS)
Others
 Please Specify:
Date of Collection: Time Collection:
Please tick box if specimen is sequential (2nd Or 3rd)
Please tick box if specimen is POST-MORTEM
Date/Time Received at laboratory: (to be filled up by lab personel)
SENDER'S INFORMATION IF SENT-OUT BY OTHER HOSPITAL
Hospital Name
Address
Contact & Email Region: Province: Municipality:
Requisitioner/ Disease Surveillance Office
LABORATORY RESULT (TO BE FILLED-UP BY LAB PERSONEL AFTER TESTING)
COVID-19 PCR Testing details ORF-1ab channel
Yes
No
 CT Value:
N-gene channel
Yes
No
 CT Value:
Any other COVID-19 Testing (Please give details)
MedTech-on-duty
Specimen Acceptable?
Yes
No; Why?
Comments:

4. Preferred Date and Time of Swabbing/Extraction

Note: Red Dates have available slot/s.
Date
Time

5. Payment

Bank Account Details
Upload Proof/s of Payment
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