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:_ ______________________________________________________________