Covid-19 Questionnaire

Pertinent Information

Visit Reference Number

Last Name

First Name

Middle Name

Birthday

Suffix

Occupation

Please specify

Sex

Current Address (Guide only)

VERY IMPORTANT: BELOW ADDRESS SHALL APPEAR ON YOUR TEST RESULTS PLEASE FILL UP PROPERLY.

Permanent Address

House No./Lot/Bldg.

Street/Purok/Sitio

Province

City

Barangay

Address Outside the Philippines (For Overseas Workers Only)

Have an address in the Philippines?

Yes

No

Employer's Name

Place of work

House no / bldg name

Street

City/Municipality

Province

Country

Office Phone No

Cellphone No

COVID-19 QUESTIONNAIRE (Part 1 of 4)

Informant Details (If patient unavailable)

Name of Informant

Relationship

Informant Contact No

Client Type?

COVID-19 Case (Suspect, Probable, or Confirmed)

Close Contact

For RT-PCR Testing (Not a Case of Close Contact)

Please Specify

Testing Category/Subgroup (Check all that apply)

A

B

C

D

E

F

G

H

I

J

Refer to Appendix 2

Completed a period of self-isolation related to the Coronavirus (COVID-19)?

Yes

No

State Circumstance

Length of self-isolation

History of exposure to known probable and/or confirmed COVID-19 case 14 days before the onset of signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection?*

Yes

No

Unknown

Date of contact with known COVID-19 case

Did you have previous COVID-19 related consultation?

Yes

No

Date of First Consult

Name of facility where first consult was done

COVID-19 QUESTIONNAIRE (Part 2 of 4)

Was the case admitted in a health facility

Yes

No

Date of Admission (Indicate earliest date if admitted in multiple health facilities)

Name of Facility where patient was first admitted

Region

Province

Disposition at Time Report(Provide name of hospital/isolation/quarantine facility)

Admitted in Health Facility

Quarantined in a Health Facility

Discharged

In Home Isolation

Transferred to Another Facility

Lost to Follow Up

Others

Admitted Facility Name

Date Admitted

Quarantined Facility Name

Date Quarantined

Quarantine Status

Date isolated/quarantined at home

Discharged Facility Name

Date Discharged

Transferred Facility Name

Date Transferred

Lost Follow Up Facility Name

Date Lost Follow Up

Please specify

Are you a health care worker?

Yes

No

Name of Health Facility

Location of Health Facility

Are you a returning overseas Filipino?

Yes

No

Country of Origin

OFW

Non-OFW

Are you a foreign national traveler?

Yes

No

Country of Origin

Passport Number

Are you a locally stranded individual/APOR/Traveler?

Yes

No

City, Municipality, Province of Origin

Locally Stranded Individual

Authorized Person Outside Residence / Local Traveler

Do you live in a closed setting environment(e.g prisons, residential facilities, care homes, camps etc.)?

Yes

No

Specify of Institution(e.g prisons, residential facilities, retirement, communities, care home, camps etc.

Specify Name of Institution

Has exposure for a person with Covid-19?

Known

Unknown

Unavailable

Close contact name

Close contact nature of exposure

Please specify

Close contact travel address

Last contact date

Reason of contact

Is vaccinated for covid-19?

Yes

No

Unknown

Vaccination Information

COVID-19 QUESTIONNAIRE (Part 3 of 4)symptoms-list

Experienced the following signs & symptoms for the past 14 days:

Comorbidities (Check all that apply if present)

Please Specify

Were you diagnosed to have Severe Acute Respiratory Illness?

Yes

No

Refer to Appendix 1

Chest imaging findings suggestive of COVID-19. Imaging done (Check all that apply)

Chest Radiography

Chest CT

Lung Ultrasound

None

Result for Chest Radiography

Normal

Pending

Hazy opacities, often rounded in morphology, with peripheral and lower lung distribution

Other findings

Date of Chest Radiography

Chest Radiography: Other findings, specify

Result for Chest CT

Normal

Pending

Mutiple bilateral ground glass opacities, often rounded in morphology, with peripheral and lower lung distribution

Other findings

Date of Chest CT

Chest CT: Other findings, specify

Result for Lung Ultrasound

Normal

Pending

Thickened pleural lines, B lines(multifocal, discrete, or confluent), consolidative patterns with or without air bronchograms

Other findings

Date of Lung Ultrasound

Lung Ultrasound: Other findings, specify

Have you ever tested positive using RT-PCR before?

Yes

No

Date of Specimen Collection

Date of Received

Date of Released

Type of Test

Brand of Kit

Reason for Antigen

Other Antigen Test Reason

Date of Result

Test Result

Laboratory

No. of RT-PRC swabs done

Other type of test, please specify

Outcome/Condition at Time of Report

Active (Currently admitted or in isolation/quarantine)

Recovered

Died

Improving

Transferred

Lost to follow-up

Not Applicable

Date of Recovery

Cause of Death (Fill 'N/A' if not applicable for a cause)

Immediate Cause

Antecedent Cause

Underlying Cause

Contributory Conditions

Date of Death

Additional Medical Info

Disease Report Unit

Non Health Disease Report Unit

Verified Assessment

COVID-19 QUESTIONNAIRE (Part 4 of 4)

Have you tested positive for being infected with Coronavirus (COVID 19)?:

Yes

No

Name of test

Date of test

Works in a closed setting?

Yes

No

Unknown

If existing case (check all that apply)

Please Specify

Are you currently pregnant?

Yes

No

Date of Last Menstrual Period

High-risk pregnancy?

Yes

No

Health Status at Consult

Asymptomatic

Mild

Moderate

Severe

Critical

Refer to Appendix 3

Have you been in a place with a known COVID-19 transmission 14 days before the onset of signs and symptoms? OR if Asymptomatic, 14 days before swabbing or specimen collection?

Yes, International

Yes, Local

No

Unknown Exposure

Please select at least one of the following checkboxes:

List the names of persons who were with you during this (these) occasion(s) and their contact numbers

Country of Origin

Airline/Sea Vessel

Flight/Vessel Number

Date of Departure

Date of Arrival in the Philippines

With ongoing COVID-19 community transmission?

Yes

No

Inclusive Travel Date From

Inclusive Travel Date To

History of travel/visit/work in other countries with a known COVID-19 transmission 14 days before the onset of signs and symptoms.

Yes

No

History of travel/visit/work in other local place with a known COVID-19 transmission 14 days before the onset of signs and symptoms.

Yes

No

Place of Origin

Airport Name

Airline/Sea Vessel/Bus Line/Train

Flight/Vessel No/Bus No.

Seat Bed No.

Port Entry (Philippines)

Date of Departure

City/Municipality Name for Arrival

Date of Arrival in the Current City/Municipality

Add Person

Name

Contact

Exposure Setting(ex. Householde, Work)

Confirmation

Are you sure you want to proceed with this action?

Add the details

Present

Yes

No

Date of Onset

Date of Resolution

Remarks

Add Vaccination Information

Date of Vaccination

Vaccination No.

Name of Vaccine

Dose Number(e.g. 1st, 2nd)

Vaccination Center/Facility

Region of health facility

Adverse Event/s?

Yes

No

Confirmation

Are you sure you want to proceed with this action?

Please complete!

Please make sure to fill-in the required fields, marked with *

Appendix 2

Sub-group A:

Individuals with severe/critical symptoms and relevant history of travel and/or contact.

Sub-group B:

Individuals with mild symptoms and relevant history of travel and/or contact, and considered vulnerable; vulnerable populations include those elderly and with preexisting medical conditions that predispose them to severe presentation and complications of COVID-19

Sub-group C:

Individuals with mild symptoms, and relevant history of travel and/or contact.

Sub-group D:

Individuals with no symptoms but with relevant history of travel and/or contact or high risk of exposure. These include:

D1: Contact-traced individuals.
D2: Healthcare workers, who shall be prioritized for regular testing in order to ensure the stability of our healthcare system.
D3: Returning Overseas Filipino Workers(ROF), who shall immediately be tested at the port of entry
D4: Filipino citizens in a specific locality within the Philippines who have expressed intention to return to their place of residence/home origin (Locally Stranded Individuals) may be tested subject to the existing protocols of the IATF.

Sub-group E:

Frontliners indirectly involved in health care provision in the response against COVID-19 may be tested as follows:

E1: Those with high or direct exposure to COVID-19 regardless of location may be tested up to once a week. These include the following:
1. Personnel manning the Temporary Treatment and Quarantine Facilities (LGU and Nationally-managed);
2. Personnel serving at the COVID-19 swabbing center;
3. Contact tracing personnel; and
4. Any personnel conducting swabbing for COVID-19 testing.
E2: Those who do not have high or direct exposure to COVID-19 but who live or work in Special Concern Areas may be tested up to every two to four weeks. These include the following:
1. Personnel manning Quarantine Control Points, including those from Armed Forces of the Philippines, Bureau of Fire Protection, and others;
2. National/Regional/Local Risk Reduction and Management Teams;
3. Officials from any local government/city/municipality health office (CEDSU, CESU, etc.)
4. Barangay Health Emergency Response Teams and barangay officials providing barangay border control and performing COVID-19- related tasks;
5. Personnel of Bureau of Corrections and Bureau of Jail Penology and Management;
6. Personnel manning the One-Stop-Shop in the Management of the Returning Overseas Filipinos;
7. Border control or patrol officers, such as immigration officers and the Philippine Coast Guard; and
8. Social workers providing amelioration and relief assistance to communities and performing COVID-19-related tasks

Sub-group F:

Other vulnerable patients and those living in confined spaces. These include, but are not limited to:

Pregnant patients who shall be tested during the peripartum period;
Dialysis patients;
Patients who are immunocompromised, such as those who have HIV/AIDS, inherited diseases that affect the immune system;
Patients undergoing chemotherapy or radiotherapy;
Patients who will undergo elective surgical procedures with high risk for transmission;
Any person who have had organ transplants, or have had bone marrow or stem cell transplant in the past 6 months;
Any person who is about to be admitted in enclosed institutions such as jails, penitentiaries, and mental institutions

Sub-group G:

Residents, occupants or workers in a localized area with an active COVID-19 cluster, as identified and declared by the local chief executive in accordance with existing DOH Guidelines and consistent with the National Task Force Memorandum Circular No. 02 s.2020 or the Operational Guidelines on the Application of the Zoning Containment Strategy in the Localization of the National Action Plan Against COVID-19 Response. The local chief executive shall conduct the necessary testing in order to protect the broader community and critical economic activities and to avoid a declaration of a wider community quarantine.

Sub-group H:

Frontliners in Tourist Zones:

H1: All workers and employees in the hospitality and tourism sectors in El Nido, Boracay, Coron, Panglao, Siargao and other tourist zones, as identified and declared by the Department of Tourism. These workers and employees may be tested once every four (4) weeks
H2: All travelers, whether of domestic or foreign origin, may be tested at least once, at their own expense, prior to entry into any designated tourist zone, as identified and declared by the Department of Tourism.

Sub-group I:

All workers and employees of manufacturing companies and public service providers registered in economic zones located in Special Concern Areas may be tested regularly.

Sub-group J:

Economy Workers

J1: Frontline and Economic Priority Workers, defined as those (1) who work in high priority sectors, both public and private, (2) have high interaction with and exposure to the public, and (3) who live or work in Special Concern Areas, may be tested every three months. These workers include, but are not limited to:
1. Transport and Logistics
  - Drivers of Taxis, Ride Hailing Services (two and four wheels), Buses, Public Transport Vehicles
  - Conductors
  - Pilots, Flight Attendants, Flight Engineers
  - Rail operators, mechanics, servicemen
  - Delivery staff
  - Water transport workers - ferries, inter island shipping, ports
2. Food Retail
  - Waiters, Waitresses, Bar Attendants, Baristas
  - Chefs and Cooks
  - Restaurant Managers and Supervisors
3. Education - once face to face classes resume
  - Teachers at all levels of education
  - Other school frontliners such as guidance counselors, librarians, cashiers
4. Financial Services
  - Bank tellers
5. Non-Food Retail
  - Cashiers
  - Stock clerks
  - Rerail salespersons
6. Services
  - Hairdressers, Barbers, Manicurist, Pedicurist, Massage Therapists
  - Embalmers, Morticians, Undertakers, Funeral Directors
  - Parking Lot Attendants
  - Security Guards
  - Messengers
  - Ushers, Lobby Attendants, Receptionist
  - Clergy
7. Market Vendors
8. Construction
  - Carpenters
  - Stonemasons
  - Electricians
  - Painters
  - Construction workers, including Foremen, Supervisors
  - Civil Engineers, Structural Engineers, Construction Managers
  - Crane and Tower operators
  - Elevator installer and repairers
9. Water Supply, Sewerage, Waste Management
  - Plumbers
  - Recycling and Reclamation worker/ Garbage Collectors
  - Water/Waste water engineers
  - Janitors and cleaners
10. Public Sector
  - Judges
  - Courtroom clerks, staff, and security
  - All national and local government employees rendering frontline services in Special Concern Areas
11. Mass media - Field reporters, photographers, and cameramen

Appendix 1

COVID-19 Case Definitions

Suspect COVID-19 case (two suspect case definitions A or B):

A person who meets the clinical AND epidemiological criteria:
Clinical criteria:
1. Acute onset of fever AND cough;
  OR
2. Acute onset of ANY THREE OR MORE of the following signs or symptoms: fever, cough, general weakness/fatigue¹, headache, myalgia, sore throat, coryza, dyspnoea, anorexia/nausea/vomiting, diarrhoea, altered mental status.
AND
Epidemiological criteria:
1. Residing or working in an area with high risk of transmission of the virus: for example, closed residential settings and humanitarian settings, such as camp and camp-like settings for displaced persons, any time within the 14 days prior to symptom onset;
  OR
2. Residing in or travel to an area with community transmission² anytime within the 14 days prior to symptom onset;
  OR
3. Working in health setting, including within health facilities and within households, anytime within the 14 days prior to symptom onset.
A patient with severe acute respiratory illness (SARI: acute respiratory infection with history of fever or measured fever of ≥ 38 C^∘ and cough; with onset within the last 10 days; and who requires hospitalization).

Probable COVID-19 case:

A patient who meets clinical criteria above AND is a contact of a probable or confirmed case, or epidemiologically linked to a cluster of cases which has had at least one confirmed case identified within that cluster.
A suspect case (described above) with chest imaging showing findings suggestive of COVID-19 disease*
* Typical chest imaging findings suggestive of COVID-19 include the following (Manna 2020):
- chest radiography: hazy opacities, often rounded in morphology, with peripheral and lower lung distribution
- chest CT: multiple bilateral ground glass opacities, often rounded in morphology, with peripheral and lower lung distribution
- lung ultrasound: thickened pleural lines, B lines (multifocal, discrete, or confluent), consolidative patterns with or without air bronchograms.
A person with recent onset of anosmia (loss of smell) or ageusia (loss of taste) in the absence of any other identified cause.
Death, not otherwise explained, in an adult with respiratory distress preceding death AND who was a contact of a probable or confirmed case or epidemiologically linked to a cluster which has had at least one confirmed case identified within that cluster.

Confirmed COVID-19 case:

A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms.

¹ Signs separated with slash (/) are to be counted as one sign

² Community transmission: Countries /territories/areas experiencing larger outbreaks of local transmission defined through an assessment of factors including, but not limited to: large numbers of cases not linkable to transmission chains, large numbers of cases from sentinel lab surveillance or increasing positive tests through sentinel samples (routine systematic testing of respiratory samples from established laboratories), multiple unrelated clusters in several areas of the country/territory/area.

Non COVID-19 case:

Appendix 3

Severity of the Disease

MILD:

Symptomatic patients presenting with fever, cough, fatigue, anorexia, myalgias; other non-specific symptoms such as sore throat, nasal congestion, headache, diarrhea, nausea and vomiting; loss of smell (anosmia) or loss of taste (ageusia) preceding the onset of respiratory symptoms with NO signs of pneumonia or hypoxia

MODERATE:

Adolescent or adult with clinical signs of non-severe pneumonia (e.g. fever, cough, dyspnea, respiratory rate (RR) = 21-30 breaths/minute, peripheral capillary oxygen saturation (SpO2) > 92% on room air)
Child with clinical signs of non-severe pneumonia (cough or difficulty of breathing and fast breathing [ < 2 months: > 60; 2-11 months: > 50; 1-5 years: > 40] and/or chest indrawing

SEVERE:

Adolescent or adult with clinical signs of severe pneumonia or severe acute respiratory infection as follows: fever, cough, dyspnea, RR>30 breaths/minute, severe respiratory distress or SpO2 < 92% on room air
Child with clinical signs of pneumonia (cough or difficulty in breathing) plus at least one of the following:
1. Central cyanosis or SpO2 < 90%; severe respiratory distress (e.g. fast breathing, grunting, very severe chest indrawing); general danger sign: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions
2. Fast breathing (in breaths/min): < 2 months: > 60; 2-11 months: > 50; 1-5 years: > 40.

Critical:

Patients manifesting with acute respiratory distress syndrome, sepsis and/or septic shock:

Acute Respiratory Distress Syndrome (ARDS)
1. Patients with onset within 1 week of known clinical insult (pneumonia) or new or worsening respiratory symptoms, progressing infiltrates on chest X-ray or chest CT scan, with respiratory failure not fully explained by cardiac failure or fluid overload
Sepsis
1. Adults with life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection. Signs of organ dysfunction include altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia
2. Children with suspected or proven infection and > 2 age-based systemic inflammatory response syndrome criteria (abnormal temperature [> 38.5 Â°C or < 36 Â°C); tachycardia for age or bradycardia for age if < 1year; tachypnea for age or need for mechanical ventilation; abnormal white blood cell count for age or > 10% bands), of which one must be abnormal temperature or white blood cell count
Septic Shock
1. Adults with persistent hypotension despite volume resuscitation, requiring vasopressors to maintain MAP > 65 mmHg and serum lactate level >2mmol/L
2. Children with any hypotension (SBP < Sth centile or > 2 SD below normal for age) or two or three of the following: altered mental status; bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and heart rate < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or weak pulse; fast breathing; mottled or cool skin or petechial or purpuric rash; high lactate; reduced urine output; hyperthermia or hypothermia.

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