Database: Thai Malaria Case Report - EP1 Help

Basic Information
Type of Case Report	Please Select One 1 - PCD 2 - ACD 3 - SCD 4 - Follow-up 5 - Investigation 6 - Others other type:
Clinic Name
Clinic Address	Fill Malaria Post Address Hamlet: Village No.: Tambon: District: Province:
Staff Name	(Blood slide taken by)
Patient Type	Thai Foreign1 (who has residence) Foreign2 (who has no residence)
Case Type	New case Repeated case Unknow
Case Information
Survey Date	Collcected at
Patient's name	First name: Last name:
House owner
House No.
Address of Patient	Fill Patient's Address Hamlet: Village No.: Tambon: District: Province: Country:
Age
Sex	1. Male 2. Female
Occupation	Please Select One 1 - Farmer 2 - Local trader/traveller 3 - Foreign trader/traveller 4 - Factory/Construction worker 5 - Lumberjack 6 - Plantation worker 7 - Office worker 8 - Student 9 - Housewife 10 - Soldier 11 - Unemployed 12 - Non-school child 13 - Casual job 14 - Teacher 15 - Monk 16 - Herdsman 99 - Others other occupation
Reason for Collection
Film No.
Diagnostic Result
Results	Please Select One 0. Negative 1. F --- P. falciparum 2. F+g --- Pf + gametocyte 3. Fg --- Pf gametocyte (only) 4. V --- P. vivax 5. O --- P. ovale 6. Mix --- Mixed 7. M --- P. malarie
Drugs Used (tabs)	Select Prescribed Medication C M Q T SP S Pyr Pri 5 mg Pri 15 mg Other drugs:(specificed)
Study Code
Remarks
Data Handler
Slide Receiver	Received by: Received Date:
Slide Reader	Examined by: Examined Date:
Data Entry	Entered by: Entry Date:
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[English/Chinese Ed. 中英文版] v1.2 (Dec. 2011)