| 12 | Were you done any laboratory test? |
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| |
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| Yes |
| No |
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| 13 | Were you given any medication? |
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| |
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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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| ||
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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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| |
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| Record ˚C |
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| 16 | Does the client suffer from |
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| |
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| Headache | Yes |
| No |
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| Myalgia | Yes |
| No |
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| Malaise | Yes |
| No |
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| Abdominal pains | Yes |
| No |
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| Abdominal. Distention | Yes |
| No |
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| Diarrhoea | Yes |
| No |
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| Nausea | Yes |
| No |
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| 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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| |
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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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| ||
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| Yes |
| No |
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| I don’t know |
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