Database: Thai Malaria Case Report - EP3p Help

Basic Information
Study site	Please Select One 1 - Yunnan, China 2 - Myanmar 3 - Thailand 4 - Anhui, China 99 - Other other site:
Malaria Control Agency	Hospital or VBDU:
Patient's name	First name: Last name:
Case No.
Ethnic group	Please Select One 1 - Han 2 - Jingpo 3 - Dai 4 - Achang 5 - Lisu 6 - Yao 7 - Bai 8 - Hani 9 - Tai 10 - Karen 11 - Myanmar 99 - Other other ethnic:
Date of Birth
Telephone Number
Case Information
Auxiliary Temperature	(°C)
Symptoms	Select Patient's Symptoms A. Fever B. Vomiting C. Diarrhea D. Abdomen pains E. Nausea F. Convulsions G. Headache H. Stomachache I. Loss of appetite K. Dizziness M. Coughing N. Joint pain O. Difficulty in breath P. Shivering/chills R. Others:
Taken any antimalarial?	(within last two weeks) Yes No
If yes, where they came from?	1. Hospital prescription 2. Self-medication 3. Other
If yes, what kind of antimalarials used	Select Used Antimalarials 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.Others:
Have bednet?	Yes No
If have mosquito net	Specify Net Types 1 - Regular untreated nets 2 - Regular ITN, NOT retreated in past 6 months 3 - Regular ITN, retreated with insecticides in past 6 months 4 - LLIN, Long Lasting Insecticidal Net 99 - Others:
ACD Slide Information (ONLY taken from DSS houses)
House No.
Latitude	° (in GCS WGS84 - Decimal Degree format)
Longitude	° (in GCS WGS84 - Decimal Degree format)
Elevation	meters
Study Code
PCD Slide Information (ONLY taken from Malaria Clinics)
PCD Clinic Name
Pulse	(/min)
Respiratory rate	(/min)
Hemoglobin (Hb)	(g/L)
Glycemia	(mg/dl)
Severe malaria symptom?	Yes No
If yes, please specify	Severe Malaria Symptoms 1. Coma 2. Convulsions 3. Respiratory distress 4. Acute Pulmonary edema 5. Renal failure 6. Spontaneous bleeding 7. Jaundice 8. Severe anemia [specify Hematocrit (Hct%)]% 99. Other:
If convulsion:	specify how many time per day:
If coma:	specify the coma score (Blantyre scale):
If spontaneous bleeding:	specify bleeding location:
Spleen size (type):
Final diagnosis	Please Select One 1 - Uncomplicated malaria 2 - Severe malaria 3 - Suspected malarias 4 - Other disease
Diagnostic Result (Blood-slide/RDT)
Malaria RDT result	Please Select One ND - Not-Done P - Positive N - Negative U - Undetermined
If done RDT	specify RDT test kit
If RDT is positive	specify 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
Microscopic diagnosis result	Please Select One ND - Not-Done P - Positive N - Negative U - Undetermined
If microscopy is positive	specify 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
Parasite stage	Select Parasite Stage 1 - Trophozoite 2 - Schizont 3 - Gametocyte
Parasitemia	Asexual: Gametocytes: (number of parasites per 200 leukocytes)
Specimen Storage
Filter paper	Paper ID: By staff: Alex chalermpol choosak ebaum fon jittraporn kanchana kirakorn kritsana kultida lisiying mongkol napalai oratai pangoi patchara pimtum ratiporn spaceidd surachai wanglili wanna warumporn wichai Yunnan001 Yunnan1001 Yunnan1002 zhouguofa Storage@ UCI PSU Kunming Dalian Mahidol Other
Blood-smear	Slide ID: By staff: Alex chalermpol choosak ebaum fon jittraporn kanchana kirakorn kritsana kultida lisiying mongkol napalai oratai pangoi patchara pimtum ratiporn spaceidd surachai wanglili wanna warumporn wichai Yunnan001 Yunnan1001 Yunnan1002 zhouguofa Storage@ UCI PSU Kunming Dalian Mahidol Other
Data Handler
Field Investigator	Form filled by: Form filled date:
Slide Reader	Read by: Read date:
Supervisor	Certified by: Certified date:
Data Entry	Entered by: Entry Date:
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[English/Chinese Ed. 中英文版] v1.2 (Dec. 2011)