Database: Thai Malaria Case Report - EP3 Help

Basic Information
Case No.
Malaria Control Agency	VBDO: VBDC: VBDU: Province:
Phase	1. A1 2. A2 3. B1 4. B2 5. PA 6. IA
Patient Type	Thai Foreign1 (who has residence) Foreign2 (who has no residence)
Patient's name	First name: Last name:
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
House owner
No. of house member
Address No.
Address of Patient	Fill Patient's Address Hamlet: Village No.: Tambon: District: Province:
Study Code
Slide Taker	Taken by: Collcected at
Slide Reader	Examined by: Examined date:
Parasite species	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
New Case Information
Case history	Asked patient Asked others
Date of onset	Date of first day sick:
Overnight somewhere before?	Yes No
If yes, where?	Fill Overnight Stay Address Hamlet: Village: Tambon: District: Province:
Rest in	1. the Village 2. a Farm hut 3. in the Forest 4.Unknown
First day of staying
Objective for went there
For how long (days)
History of blood transfusion	Yes No
If yes, when?
Repeated Case Information (within 3 months)
Date of last positive
Last positive species	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
Date of last radical treatment
Taken full dose?	Completed Not completed
Has vomit?	Vomit No vomit
Last Medication	Select the Taken Medication 1.DHA/Piperaquine 2.Artemether 3.Pyronaridine 4.Chloroquine 5.Artesunate 6.DHA 7.Primaquine 8.Mefloquine 9.Tetracycline/Doxycycline 10.Sulfadoxine/Pyrimethamine 11.Quinine/Quinidine 12.Don't know 99.Other:
Travelling after treated?	Yes No
If yes, where?	Fill Where Travelled to Hamlet: Village: Tambon: District: Province:
and travelled date
Treatment History
Present radical treatment?	1. Yes 2. Pass 3. By hospital 0. No
Date of present treatment
Present Medication	Select Prescribed Medication 1.DHA/Piperaquine 2.Artemether 3.Pyronaridine 4.Chloroquine 5.Artesunate 6.DHA 7.Primaquine 8.Mefloquine 9.Tetracycline/Doxycycline 10.Sulfadoxine/Pyrimethamine 11.Quinine/Quinidine 12.Don't know 99.Other:
Case Classification
New case classification	Please Select One 1 - A 2 - Bx 3 - By 4 - Bz 5 - Bo 6 - Bf 7 - C 8 - D 9 - E 0 - F
Repeated case classification	Please Select One 1 - Not cure 2 - New infect 0 - No investigation
Classification of new infection	Please Select One 1 - A 2 - Bx 3 - By 4 - Bz 5 - Bo 6 - Bf 7 - C 8 - D 9 - E 0 - F
Foci of infection	1.the Village 2.a Farm hut 3.in the Forest 4.Unknown
Address of Foci	Fill Foci Address Hamlet: Village: Tambon: District: Province: Country:
Terrain of Foci (Explain)
Mosquito Prevention
Mosquito net used?	Yes No
How many bednets?
How many Impregnated Nets (ITN)?
Always used mosquito nets
Sleep under bednet in foci area?	Yes No
Use repellants?	Yes No
Residual sprayed for foci area?	Yes No Unknown
Do house/hut of patient be sprayed?	Yes No Unknown
Other Person Check?	(Such as household visit or mass blood survey): Yes No
Data Handler
Investigator	Investigated by: Position: Date:
Inspector	Inspected by: Position: Date:
Data Entry	Entered by: Entry Date:
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[English/Chinese Ed. 中英文版] v1.2 (Dec. 2011)