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