LinkId Text Cardinality Type Description & Constraints Questionnaire-SOTT0CaseInvestigationForm T0 Case Investigation Questionnaire Questionnaire http://worldhealthorganization.github.io/smart-ot/Questionnaire/Questionnaire-SOTT0CaseInvestigationForm#0.2.1 investigationForm T0 Initial Case Investigation Form 0..1 group Demographics Section 1: Patient Information 0..1 group Name Name 0..1 string identification Identification 0..1 string telephone Telephone 0..1 string BirthDate Birth Date 0..1 date Sex Sex at birth 0..1 choice Value Set: SOT Biological Sex estimatedAge Estimated Age in years/months/days 0..1 string occupation Occupation 0..1 string healthServiceName If working in a health facility, specify name and locality 0..1 string address Residential street address 0..1 string province Admin Level 1 - province 0..1 string district Admin Level 2 - district 0..1 string commune Admin Level 3 - commune 0..1 string ward Admin Level 4 - ward , parish 0..1 string latitude GPS residence latitude 0..1 string longitude GPS residence longitude 0..1 string Clinical Section 2: Clinical Information 0..1 group clinicalCourse Patient clinical course 0..1 group symptomOnsetDate date of onset of symptoms*:____/____/______ 0..1 date presentedToHCFDate For this episode, date first presented to health facility:___/___/_____ 0..1 date admitted Currently admitted in health facility ?: 0..1 choice Value Set: SOT Yes No admittedHCFName name: 0..1 string Enable When: admitted = Yes (expandedYes-NoIndicator#Y) outcome Outcome of illness*: 0..1 choice Value Set: Patient Clinical Course Outcome outcomeEvaluatedDate date outcome was evaluated:___/___/_____ 0..1 date outcomeDate date* of recovery, default or death:___/___/_____ 0..1 date symptoms Patient symptoms at presentation - check all reported symptoms 0..1 group fever History of fever 0..1 choice Value Set: Yes No Unknown fatigue Intense fatigue or weakness 0..1 choice Value Set: Yes No Unknown irritability Irritability/confusion 0..1 choice Value Set: Yes No Unknown headache Head pain 0..1 choice Value Set: Yes No Unknown soreThroat Sore throat 0..1 choice Value Set: Yes No Unknown intenseCough Non-productive cough 0..1 choice Value Set: Yes No Unknown expectoration Productive cough (expectoration) 0..1 choice Value Set: Yes No Unknown anorexia Loss of appetite 0..1 choice Value Set: Yes No Unknown diarrhoea Passing rice water-like stool 0..1 choice Value Set: Yes No Unknown nausea Nausea/vomiting 0..1 choice Value Set: Yes No Unknown intensePain Intense pain 0..1 choice Value Set: Yes No Unknown musclePain Muscular pain 0..1 choice Enable When: intensePain = Yes (YesNoUnknown#Yes) Value Set: Yes No Unknown chestPain Chest pain 0..1 choice Value Set: Yes No Unknown abdominalPain Abdominal pain 0..1 choice Value Set: Yes No Unknown jointPain Joint pain 0..1 choice Value Set: Yes No Unknown signs Patient signs at presention - check all observed signs 0..1 group conjunctivitalInjection Conjunctival injection 0..1 choice Value Set: Yes No Unknown palpableLiver Palpable liver 0..1 choice Value Set: Yes No Unknown palpableSpleen Palpable spleen 0..1 choice Value Set: Yes No Unknown jaundice Jaundice 0..1 choice Value Set: Yes No Unknown lymphadenopathy Enlarged lymph nodes 0..1 choice Value Set: Yes No Unknown lymphadenopathySite site (enlarged nymph nodes) 0..1 string oedema Peripheral oedemas 0..1 choice Value Set: Yes No Unknown seizures Seizures 0..1 choice Value Set: Yes No Unknown coma Drowsiness, coma 0..1 choice Value Set: Yes No Unknown stiffNeck Neck stiffness 0..1 choice Value Set: Yes No Unknown bleeding Observed abnormal bleeding 0..1 choice Value Set: Yes No Unknown otherSignsSymptoms Other signs , specify 0..1 string Value Set: Yes No Unknown heartrate Heart rate (beats per min) 0..1 quantity Bp Blood Pressure (mmHg): 0..1 group sysBp Systolic blood pressure 0..1 quantity diaBp Diastolic blood pressure 0..1 quantity RespiratoryRate Respiratory rate (per min) 0..1 quantity O2Sat O2 saturation room air 0..1 quantity temperature Temperature (degrees): 0..1 quantity crt Capillary refill time> 3 sec 0..1 choice Value Set: Yes No Unknown muac MUAC (cm): 0..1 quantity comorbidity Underlying conditions and comorbidity - check all that apply 0..1 group pregnancy Pregancy 0..1 choice Value Set: Yes No Unknown postPartum Post-partum (<6 weeks after delivering) 0..1 choice malnutrition Malnutrition 0..1 choice Value Set: Yes No Unknown immunodeficiency Immunodeficiency 0..1 choice Value Set: Yes No Unknown acuteChronicDisease Associated acute or chronic disease, please specifiy 0..1 choice Value Set: Yes No Unknown specifyAcuteChronicDisease if yes, name: 0..1 string otherConditions Other conditions impacting health, specify 0..1 string Exposure Section 3: Exposure and travel Information 3 WEEKS PRIOR TO FIRST SYMPTOM ONSET 0..1 group sickContact Are you aware of people outside your household with similar illness or symptoms ? 0..1 choice DateOfOnset Date of onset 0..1 date nameAndRelationship Name and relationship 0..1 string placeOfInteraction Place of interaction 0..1 string massGatheringParticipation Did the patient participate in mass gathering events 0..1 choice Value Set: Yes No Unknown massGetheringDetails Mass Gathering details 0..* group Value Set: Yes No Unknown dateOfEvent Date of event 0..1 date eventLocation Location 0..1 string gatheringType Type of gathering and how many people attended 0..1 string Did you travel* outside your residential area ? Did you travel* outside your residential area ? 0..1 choice travelDetails Travel Details 0..* group Value Set: Yes No Unknown Date of travel Date of travel 0..1 date placeOfTravel From where to where 0..1 string traditionalTreatment Traditional treatment received 0..1 choice specifyTraditionalTreatment Specify traditional treatment 0..1 string animalContact Were you in close proximity to any animals in the XX week/months prior to symptom onset? 0..1 choice Value Set: Yes No Unknown Any other information regarding animal health events near the patient Any other information regarding animal health events near the patient 0..1 string specifyInsectExposure Specify the insect and exposure 0..1 string foodDiseaseSuspected Does the patient suspect a specific food or the beverage to be the cause of the disease 0..1 choice Value Set: Yes No Unknown explainSuspicion Explain why this suspicion 0..1 string Laboratory Section 4: Laboratory Information 0..1 group labName Name of testing laboratory: 0..1 string labLocation Location of testing laboratory 0..1 string antibioticReceived Did the patient received antibiotic prior to specimen collection? 0..1 choice Value Set: Yes No Unknown labtest Lab test details 0..* group sampleId Sample ID 0..1 string collectionDate Collection date 0..1 date testPerformed Test performed 0..1 string result Result 0..1 quantity proteinuria Proteinuria 0..1 quantity hematuria Hematuria 0..1 quantity haemoglobin Haemoglobin (-g/l) 0..1 quantity WBC WBC count 0..1 quantity platelet Platelets 0..1 quantity CRP CRP: 0..1 quantity potassium Potassium 0..1 quantity ALT ALT/SGPT 0..1 quantity AST AST/SGOT 0..1 quantity lactate Lactate 0..1 quantity totalBilirubin Total bilirubin 0..1 quantity creatinine Creatinine 0..1 quantity urea Urea 0..1 quantity kinase Creatine kinase 0..1 quantity otherBloodTest Other blood test: 0..1 string Documentation for this format
If working in a health facility, specify name and locality
date of onset of symptoms*:____/____/______
For this episode, date first presented to health facility:___/___/_____
Currently admitted in health facility ?:
date outcome was evaluated:___/___/_____
date* of recovery, default or death:___/___/_____
Patient symptoms at presentation - check all reported symptoms
Patient signs at presention - check all observed signs
Underlying conditions and comorbidity - check all that apply
Associated acute or chronic disease, please specifiy
Other conditions impacting health, specify
Section 3: Exposure and travel Information 3 WEEKS PRIOR TO FIRST SYMPTOM ONSET
Are you aware of people outside your household with similar illness or symptoms ?
Did the patient participate in mass gathering events
Type of gathering and how many people attended
Did you travel* outside your residential area ?
Were you in close proximity to any animals in the XX week/months prior to symptom onset?
Any other information regarding animal health events near the patient
Does the patient suspect a specific food or the beverage to be the cause of the disease
Did the patient received antibiotic prior to specimen collection?