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.