Contact Details Form
Demographics
Family Name:
*
Given Name:
*
Middle Name:
Gender:
*
...
Male
Female
Will Record Date of Birth...
*
...
By Birth-date
By Age
Select Birthdate
*
Is this birthdate an estimate?
*
...
Yes
No
Age:
Years
*
Months
*
Was contact available
*
Yes
No
Unknown
Attributes
Telephone (mobile) number:
Nationality:
Next of kin:
Next of kin's phone number:
Housing
*
Own
Shared
Occupation
*
Medical Officers
Registrars
Consultant Doctors
Clinical Officers
Nurse
Laboratory Personnel
Other Health worker
Other Hospital Worker
Other
Specify:
*
Please fill out Occupation Exposure Form as Contact is a healthcare worker
Name Of Case
*
Where contact with case occured
*
Healthcare
Household
Workplace
Education
Travel
Other
Specify:
*
Any underlying clinical conditions
*
Yes
No
Unknown
Underlying Condition
*
Chronic heart disease
Chronic kidney disease
Diabetes
Hypertension
Immunodeficiency (include HIV)
Chronic neurological disease
Chronic respiratory disease
Asthma requiring medication
Chronic liver disease
Body Mass Index > 40
Malignancy
Other comorbidities
Specify:
*
Pregnant
*
Yes
No
Unknown
Travel History
*
Yes
No
Last Travel Country:
*
Last Travel City:
*
Date of Arrival:
*
Encounter Location:
*
Encounter Location
*
...
Provider Name:
Provider's System Id:
*
Encounter Date
*