Daily Surveillance
Demographics
Contact ID:
Family Name:
Given Name:
Middle Name:
Name:
Gender:
...
Male
Female
Date of birth:
Telephone (mobile) number:
Surveillance Start Date
Surveillance End Date
Date of Surveillance:
*
Day of Follow up
Temperature
Symptoms Present
*
Yes
No
Fever(>=38 or history of fever)
*
Yes
No
Unknown
Date:
*
Sore throat
*
Yes
No
Unknown
Date:
*
Runny nose
*
Yes
No
Unknown
Date:
*
Cough
*
Yes
No
Unknown
Date:
*
Shortness of breath
*
Yes
No
Unknown
Date:
*
Vomiting
*
Yes
No
Unknown
Date:
*
Nausea
*
Yes
No
Unknown
Date:
*
Diarrhoea
*
Yes
No
Unknown
Date:
*
Loss of smell
*
Yes
No
Unknown
Date:
*
Loss of Taste
*
Yes
No
Unknown
Date:
*
Headache
*
Yes
No
Unknown
Date:
*
Fatigue
*
Yes
No
Unknown
Date:
*
Muscle or Body Aches
*
Yes
No
Unknown
Date:
*
Other Symptoms
Outcome
*
Dead
Lost to follow up
Asymptomatic
Symptomatic
Details of lost to follow up
*
Has COVID-19 testing been ordered
*
Yes
No
Unknown
Test results
*
Positive
Negative
Indeterminate
Unknown
Please order COVID-19 test
Patient plan
*
Continue monitoring
Due for testing
Refer contact to care and treatment team
Exit (Discharge patient from program)
Encounter Location:
*
Public Health Team Member:
*
Public Health Team Member's System ID:
*