Date of Assessment ___/___/__ (dd/mm/yy)
Age: _______ Sex: ______________ Occupation: _______________
Married (Y/N): _______________ Children (Y/N, number): _______________
Date of Exposure From ___/___/___ (YY/MM/DD) To ___/___/___ (YY/MM/DD)
Type of Exposure
If yes, Hong Kong or Guandong, China or Taiwan or
Hanoi, Vietnam or Singapore
From ___/___/__ (YY/MM/DD) To ___/___/__ (YY/MM/DD)
Close Contact to a person with “suspect or probable SARS case” or “quarantined person”
Other, specify: ______________________________
Setting of Exposure (Ö all that applies):
Occupational exposure (i.e. the patient being assessed is a healthcare worker)
If yes, what precautions were taken? (Ö all that applies):
other, specify: __________________
face-to-face (within 1 meter) contact
contact with respiratory secretions (ie. Fluid from mouth/nose)
Other form of contact _________________________________
Who was the patient in exposed to? __________________________
Where ? Scarborough Grace Hospital
Other ______________
Date of Illness Onset of Symptoms ___/___/__ (YY/MM/DD)
|
Symptom |
Yes |
No |
Duration and/or Date of Onset (YY/MM/DD) |
|
Fever (> 38° C) |
|
||
|
Cough |
|
||
|
Sore throat |
|
||
|
Myalgia |
|
||
|
Headache |
|
||
|
SOB / difficulty breathing |
|
||
|
Diarrhea |
|
||
|
Loss of appetite |
|
||
|
Nausea |
|
||
|
Vomiting |
|
||
|
Rash |
|
||
|
Confusion |
|
||
|
Other Symptoms
|
|
|
|
____________________________________________________________________________________________________________________________________________________________
Anemia, thalassemia, sickle cell anemia, other ____________ (circle)
Kidney disease, if yes ________________________________
Heart disease, if yes ________________________________
Liver disease, if yes ________________________________
INR: _________ PTT: __________ Platelet count: _________
Cr: _________ urea: _________ BS: _________
Mg: ________ Ca: _________ Albumin: _________
AST*: _______ ALT*: _________ ALP: _________ Bilirubin: _________
LDH*: ________ CK*: ________ Lipase*: _________
CXR: __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________
ECG: __________________________________________________________________
Assessment:
____________________________________________________________________________________________________________________________________________________________
Plan:
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
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Prepared by Marie Louie