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.