Email Temporary address (if different from permanent address Telephone (temporary home) Telephone (mobile) Email Aboriginal Torres Strait Both origin Islander origin Aboriginal and Torres Indigenous Status Strait Islander origin Not Unknown Aboriginal or Torres Strait Islander Ethnicity – specify Country of birth – specify CLINICAL 4 Date of symptom onset __ /__ /____ dd/mm/yyyy DETAILS fever malaise myalgia Febrile phase headache pharyngitis conjunctival injection vomiting diarrhoea bloody diarrhoea abdominal rash petechiae pain Other symptoms –specify Hypotension Spontaneous Oedema Complications bleeding Shock Neurologic Multi-organ involvement failure Other complications – specify Yes No Unknown HOSPITAL and 5 TREATMENT Hospitalised DETAILS Date admitted __ /__ /____ Date discharged __ /__ /____ Name of hospital – specify Yes No Unknown Isolated in single room ICU HDU Unknown Admitted to ICU or HDU
Email Temporary address (if different from permanent address Telephone (temporary home) Telephone (mobile) Email Indigenous Status Aboriginal origin Torres Strait Islander origin Both Aboriginal and Torres Strait Islander origin Not Aboriginal or Torres Strait Islander Unknown Ethnicity – specify Country of birth – specify 4 CLINICAL DETAILS Date of symptom onset __ /__ /____ dd/mm/yyyy Febrile phase fever malaise myalgia headache pharyngitis conjunctival injection vomiting diarrhoea bloody diarrhoea abdominal pain rash petechiae Other symptoms –specify Complications Hypotension Spontaneous bleeding Oedema Shock Neurologic involvement Multi-organ failure Other complications – specify 5 HOSPITAL and TREATMENT DETAILS Hospitalised Yes No Unknown Date admitted __ /__ /____ Date discharged __ /__ /____ Name of hospital – specify Isolated in single room Yes No Unknown Admitted to ICU or HDU ICU HDU Unknown
EVD-SoNG.docx