A. Demographic Information

Add New Hospital | Hospital Name: |

Date of Enrollment :

1. Name of Patient & Initials^*

2. Age Category^*

3. Age

4. Gender^*

5. Name of Father/ Mother

6.Contact No

7.Address

8.UHID/Hospital Ref ID^*

9. Remarks, if any

Signs and Symptoms
Fever	Yes No
Fever Temperature
Fever Duration
Fever Grade	High Grade Low Grade
Fever On & Off	Yes No
Fever continuous	Yes No
Night Sweats	Yes No
Evening rise of temperature	Yes No
Relieved on taking Antipyretics (eg Paracetamol)	Yes No
Cough	Yes No
Loose Stools	Yes No
Vomiting	Yes No
Pain on Passing Urine	Yes No
Sore Throat	Yes No
Shortness of Breath	Yes No
Chest Pain	Yes No
Loss of Weight	Yes No
Loss of appetite	Yes No
Any Blood in Sputum	Yes No
Weakness	Yes No
Enlarged lymph nodes cervical	Yes No
Enlarged lymph nodes axillary	Yes No
Enlarged lymph nodes inguinal region	Yes No
History of smoking	Yes No
Any other Signs or Symptoms :
Additional history, in case of child
Feeding well	Yes No
Active	Yes No
Weight Loss in last 3 months	Yes No
Failure to gain weight in last 3 months	Yes No
Recurrent Abdominal Pain	Yes No
Seizures	Yes No
Irritability	Yes No
Lethargy	Yes No
Drowsiness	Yes No
Any other, Please Specify


Any Investigation already done :	1. 2.
Provisional diagnosis (by Physician) :
New Investigations _{(Mention all Investigations &results here. Upload all reports) :}
Date of chest X-ray :
Any other Investigation (USG, CT,MRI etc) :
Physician/Radiologist Observation/Report _{(Upload the report) :}
Final Diagnosis by Physician :
Category of x-ray diagnosis :
--Selct One-- :
Specific investigations: Chest X-ray _{to be upload :}
Any other remarks :
Comment by Site :
Treatment Initiation :
CRF Filled By:
CRF Verified by _{To be done by PI/Co-PI):}