| FEVER MONITORING No.…………………… Last name and First name: …………………………………………………………. | |||||
| Reporting criteria: any axillary temperature (corrected) greater than or equal to 38˚C | |||||
| Date of consultation: |__|__| / |__|__| /|__|__|__|__| | Center: ………………………………………………… | ||||
| Care giver name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__| | |||||
| Patient number in the center's registry: |__|__|__|__|__|__| | |||||
| Sex Male Female | Date of Birth: |__|__|/|__|__|/|__|__|__|__| Age: |__|__|years |__|__|months | ||||
| Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| | Phone: |__|__|__|__|__|__|__|__|__| | ||||
| SUSPICION AND DIAGNOSIS | |||||
| Axillary temperature (corrected) upon admission: |__|__|,|__| °C | Duration since onset of fever: |__|__| days | ||||
| Cough | Suspected Malaria | RDT done: no yes | RDT Result: Positive Negative | ||
| Thick blood film done: no yes | Thick blood film Result: Positive Negative | ||||
| Flu Syndrome | Case type ILI SARI | ||||
| Consent request for sampling no yes | |||||
| Sampling done no yes | |||||
| Nature of the sampling
Nasal swab Throat swab Blood | Sampling Date
|__|__| / |__|__| /|__|__|__|__| |__|__| / |__|__| /|__|__|__|__| |__|__| / |__|__| /|__|__|__|__| | ||||
| Others Signs: ( Check boxes if the sign is present) | |||||
| Sore throat | Nausea | Clinical anemia | Splenomegaly | ||
| Runny rose | Vomiting | Asthenia | Headache | ||
| Oculo-nasal catarrh | Diarrhea | Myalgia | Others…………………………………. | ||
| Sub-costal retractions | Chills | Convulsion | |||
| Dyspnea | Inability to drink or breastfeed | ||||
| Risk Factors (Check boxes if the risk factor is present) | |||||
| Asthma | Diabetes | Sick cell disease |
| ||
| Heart disease | Malnutrition | Obesity |
| ||
| Travel within the last 15 days | no yes if yes, specify location: …………………… | ||||
| Presence of other people with the same symptomatology surrounding: no yes | |||||
| Treatment before admission no yes (Check the box if treatment prescribed ) | |||||
| Antibiotics | Antimalarias | Antihistamines | Antipyretics | ||
| Bronchodilators, | Others…………………………………………………………………….. | ||||
| SARI Diagnosis (Choose one option) | |||||
| Isolated upper respiratory disease Lower respiratory disease with wheezing Exacerbation of asthma | |||||