12 | Were you done any laboratory test? |
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| |
| Yes |
| No |
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13 | Were you given any medication? |
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| |
| No |
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| Yes |
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| (If YES and aware indicate name) |
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| ||
14 | How long have you taken the medicine? |
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| ||
| In days |
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| I don’t know |
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PART 2: CLINICAL CHARACTERISTICS | |||||
15 | Is the client having a fever? |
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| |
| Record ˚C |
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16 | Does the client suffer from |
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|
| |
| Headache | Yes |
| No |
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| Myalgia | Yes |
| No |
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| Malaise | Yes |
| No |
|
| Abdominal pains | Yes |
| No |
|
| Abdominal. Distention | Yes |
| No |
|
| Diarrhoea | Yes |
| No |
|
| Nausea | Yes |
| No |
|
| Cough | Yes |
| No |
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| Mental confusion | Yes |
| No |
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| Stupor | Yes |
| No |
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| Coma | Yes |
| No |
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17 | General condition? (rate) |
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| |
| Severe |
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| Moderate |
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| Mild |
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18 | Stool consistency? |
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| Loose/watery |
| Formed |
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| Blood stained |
| Semi-formed |
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| Mucoid |
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19 | How often do you use the latrine/toilet? |
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| ||
| Always |
| Sometimes |
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| Often |
| Never |
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20 | Does your latrine/toilet have a cover? |
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| ||
| Yes |
| No |
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| I don’t know |
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