WHO SMART Guideline: Surveillance and Outbreak Toolkit
0.2.1 - CI Build International flag

WHO SMART Guideline: Surveillance and Outbreak Toolkit, published by WHO. This is not an authorized publication; it is the continuous build for version 0.2.1. This version is based on the current content of https://github.com/WorldHealthOrganization/smart-ot and changes regularly. See the Directory of published versions

Questionnaire: T0 Case Investigation Questionnaire

Branch:
LinkIdTextCardinalityTypeDescription & Constraintsdoco
.. Questionnaire-SOTT0CaseInvestigationFormT0 Case Investigation QuestionnaireQuestionnairehttp://worldhealthorganization.github.io/smart-ot/Questionnaire/Questionnaire-SOTT0CaseInvestigationForm#0.2.1
... investigationFormT0 Initial Case Investigation Form0..1group
.... DemographicsSection 1: Patient Information0..1group
..... NameName0..1string
..... identificationIdentification0..1string
..... telephoneTelephone0..1string
..... BirthDateBirth Date0..1date
..... SexSex at birth0..1choiceValue Set: SOT Biological Sex
..... estimatedAgeEstimated Age in years/months/days0..1string
..... occupationOccupation0..1string
..... healthServiceNameIf working in a health facility, specify name and locality0..1string
..... addressResidential street address0..1string
..... provinceAdmin Level 1 - province0..1string
..... districtAdmin Level 2 - district0..1string
..... communeAdmin Level 3 - commune0..1string
..... wardAdmin Level 4 - ward , parish0..1string
..... latitudeGPS residence latitude0..1string
..... longitudeGPS residence longitude0..1string
.... ClinicalSection 2: Clinical Information0..1group
..... clinicalCoursePatient clinical course0..1group
..... symptomOnsetDatedate of onset of symptoms*:____/____/______0..1date
..... presentedToHCFDateFor this episode, date first presented to health facility:___/___/_____0..1date
..... admittedCurrently admitted in health facility ?:0..1choiceValue Set: SOT Yes No
..... admittedHCFNamename:0..1stringEnable When: admitted = Yes (expandedYes-NoIndicator#Y)
..... outcomeOutcome of illness*:0..1choiceValue Set: Patient Clinical Course Outcome
..... outcomeEvaluatedDatedate outcome was evaluated:___/___/_____0..1date
..... outcomeDatedate* of recovery, default or death:___/___/_____0..1date
..... symptomsPatient symptoms at presentation - check all reported symptoms0..1group
...... feverHistory of fever0..1choiceValue Set: Yes No Unknown
...... fatigueIntense fatigue or weakness0..1choiceValue Set: Yes No Unknown
...... irritabilityIrritability/confusion0..1choiceValue Set: Yes No Unknown
...... headacheHead pain0..1choiceValue Set: Yes No Unknown
...... soreThroatSore throat0..1choiceValue Set: Yes No Unknown
...... intenseCoughNon-productive cough0..1choiceValue Set: Yes No Unknown
...... expectorationProductive cough (expectoration)0..1choiceValue Set: Yes No Unknown
...... anorexiaLoss of appetite0..1choiceValue Set: Yes No Unknown
...... diarrhoeaPassing rice water-like stool0..1choiceValue Set: Yes No Unknown
...... nauseaNausea/vomiting0..1choiceValue Set: Yes No Unknown
...... intensePainIntense pain0..1choiceValue Set: Yes No Unknown
...... musclePainMuscular pain0..1choiceEnable When: intensePain = Yes (YesNoUnknown#Yes)
Value Set: Yes No Unknown
...... chestPainChest pain0..1choiceValue Set: Yes No Unknown
...... abdominalPainAbdominal pain0..1choiceValue Set: Yes No Unknown
...... jointPainJoint pain0..1choiceValue Set: Yes No Unknown
..... signsPatient signs at presention - check all observed signs0..1group
...... conjunctivitalInjectionConjunctival injection0..1choiceValue Set: Yes No Unknown
...... palpableLiverPalpable liver0..1choiceValue Set: Yes No Unknown
...... palpableSpleenPalpable spleen0..1choiceValue Set: Yes No Unknown
...... jaundiceJaundice0..1choiceValue Set: Yes No Unknown
...... lymphadenopathyEnlarged lymph nodes0..1choiceValue Set: Yes No Unknown
...... lymphadenopathySitesite (enlarged nymph nodes)0..1string
...... oedemaPeripheral oedemas0..1choiceValue Set: Yes No Unknown
...... seizuresSeizures0..1choiceValue Set: Yes No Unknown
...... comaDrowsiness, coma0..1choiceValue Set: Yes No Unknown
...... stiffNeckNeck stiffness0..1choiceValue Set: Yes No Unknown
...... bleedingObserved abnormal bleeding0..1choiceValue Set: Yes No Unknown
...... otherSignsSymptomsOther signs , specify0..1stringValue Set: Yes No Unknown
...... heartrateHeart rate (beats per min)0..1quantity
...... BpBlood Pressure (mmHg):0..1group
....... sysBpSystolic blood pressure0..1quantity
....... diaBpDiastolic blood pressure0..1quantity
...... RespiratoryRateRespiratory rate (per min)0..1quantity
...... O2SatO2 saturation room air0..1quantity
...... temperatureTemperature (degrees):0..1quantity
...... crtCapillary refill time> 3 sec0..1choiceValue Set: Yes No Unknown
...... muacMUAC (cm):0..1quantity
..... comorbidityUnderlying conditions and comorbidity - check all that apply0..1group
...... pregnancyPregancy0..1choiceValue Set: Yes No Unknown
...... postPartumPost-partum (<6 weeks after delivering)0..1choice
...... malnutritionMalnutrition0..1choiceValue Set: Yes No Unknown
...... immunodeficiencyImmunodeficiency0..1choiceValue Set: Yes No Unknown
...... acuteChronicDiseaseAssociated acute or chronic disease, please specifiy0..1choiceValue Set: Yes No Unknown
...... specifyAcuteChronicDiseaseif yes, name:0..1string
...... otherConditionsOther conditions impacting health, specify0..1string
.... ExposureSection 3: Exposure and travel Information 3 WEEKS PRIOR TO FIRST SYMPTOM ONSET0..1group
..... sickContactAre you aware of people outside your household with similar illness or symptoms ?0..1choice
..... DateOfOnsetDate of onset0..1date
..... nameAndRelationshipName and relationship0..1string
..... placeOfInteractionPlace of interaction0..1string
..... massGatheringParticipationDid the patient participate in mass gathering events0..1choiceValue Set: Yes No Unknown
..... massGetheringDetailsMass Gathering details0..*groupValue Set: Yes No Unknown
...... dateOfEventDate of event0..1date
...... eventLocationLocation0..1string
...... gatheringTypeType of gathering and how many people attended0..1string
...... Did you travel* outside your residential area ?Did you travel* outside your residential area ?0..1choice
..... travelDetailsTravel Details0..*groupValue Set: Yes No Unknown
...... Date of travelDate of travel0..1date
...... placeOfTravelFrom where to where0..1string
...... traditionalTreatmentTraditional treatment received0..1choice
..... specifyTraditionalTreatmentSpecify traditional treatment0..1string
..... animalContactWere you in close proximity to any animals in the XX week/months prior to symptom onset?0..1choiceValue Set: Yes No Unknown
..... Any other information regarding animal health events near the patientAny other information regarding animal health events near the patient0..1string
..... specifyInsectExposureSpecify the insect and exposure0..1string
..... foodDiseaseSuspectedDoes the patient suspect a specific food or the beverage to be the cause of the disease0..1choiceValue Set: Yes No Unknown
..... explainSuspicionExplain why this suspicion0..1string
.... LaboratorySection 4: Laboratory Information0..1group
..... labNameName of testing laboratory:0..1string
..... labLocationLocation of testing laboratory0..1string
..... antibioticReceivedDid the patient received antibiotic prior to specimen collection?0..1choiceValue Set: Yes No Unknown
..... labtestLab test details0..*group
...... sampleIdSample ID0..1string
...... collectionDateCollection date0..1date
...... testPerformedTest performed0..1string
...... resultResult0..1quantity
..... proteinuriaProteinuria0..1quantity
..... hematuriaHematuria0..1quantity
..... haemoglobinHaemoglobin (-g/l)0..1quantity
..... WBCWBC count0..1quantity
..... plateletPlatelets0..1quantity
..... CRPCRP:0..1quantity
..... potassiumPotassium0..1quantity
..... ALTALT/SGPT0..1quantity
..... ASTAST/SGOT0..1quantity
..... lactateLactate0..1quantity
..... totalBilirubinTotal bilirubin0..1quantity
..... creatinineCreatinine0..1quantity
..... ureaUrea0..1quantity
..... kinaseCreatine kinase0..1quantity
..... otherBloodTestOther blood test:0..1string

doco Documentation for this format