Where There Is No Doctor 2011
PATIENT REPORT
TO USE WHEN SENDING FOR MEDICAL HELP
Name of the sick person:_ __________________________________________Age:______
Male_ ______ Female________ Where is he (she)?_________________________________
What is the main sickness or problem right now?_________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
When did it begin?___________________________________________________________
How did it begin?____________________________________________________________
Has the person had the same problem before?____________When?_ _______________
Is there fever?_________ How high?_ ________ ° When and for how long?____________
Pain?___________Where?________________________What kind?____________________
What is wrong or different from normal in any of the following?
Skin:_____________________________ Ears:_______________________________
Eyes:_ __________________________ Mouth and throat:_______________________
Genitals:_ __________________________________________________________________
Urine: Much or little?________________Color?_______________Trouble urinating?_____
Describe:_________________________ Times in 24 hours:________ Times at night:_____
Stools: Color?_________________ Blood or mucus?_______________ Diarrhea?_______
Number of times a day:__________ Cramps?_________ Dehydration?__________Mild or
severe?________________ Worms?___________ What kind?_ ________________________
Breathing: Breaths per minute:____________ Deep, shallow, or normal?_____________
Difficulty breathing (describe):_________________________ Cough (describe):_______
_____________________Wheezing?___________ Mucus?____________ With blood?_____
Does the person have any of the SIGNS OF DANGEROUS ILLNESS listed on
page 42?_ __________Which? (give details)______________________________________
____________________________________________________________________________
Other signs:________________________________________________________________
Is the person taking medicine?_ __________ What?________________________________
Has the person ever used medicine that has caused a rash, hives (or bumps)
with itching, or other allergic reactions?____________ What?_______________________
The state of the sick person is: Not very serious:_________________Serious:_________
Very serious:_ _________________
On the back of this form write any other information you think may be important.