Coronavirus disease (COVID-19) technical guidance by WHO Household transmission investigation protocol | Page 31

Loss of appetite
Nose bleed
Fatigue
Seizures
Altered consciousness
Other neurological signs □ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
If Yes, specify:
Other symptoms □ Yes □ No □ Unknown
If Yes, specify:
7. Primary case pre-existing condition(s)
Pregnancy
Obesity □ Yes □ No □ Unknown
If Yes, specify trimester:
□ First □ Second □ Third □ Unknown
□ Yes □ No □ Unknown
Cancer □ Yes □ No □ Unknown
Diabetes □ Yes □ No □ Unknown
HIV/other immune deficiency □ Yes □ No □ Unknown
Heart disease □ Yes □ No □ Unknown
Asthma (requiring medication) □ Yes □ No □ Unknown
Chronic lung disease (non-asthma) □ Yes □ No □ Unknown
Chronic liver disease □ Yes □ No □ Unknown
Chronic haematological disorder □ Yes □ No □ Unknown
Chronic kidney disease □ Yes □ No □ Unknown
Chronic neurological impairment/disease □ Yes □ No □ Unknown
Organ or bone marrow recipient □ Yes □ No □ Unknown
Other pre-existing condition(s) □ Yes □ No □ Unknown
If Yes, specify:
8. Report of laboratory results
Please impute laboratory results once they become available in the “Laboratory results report”
9. Status of form completion
Form completed
□ Yes □ No or par ally
If No or partially, reason:
□ Missed
□ Not a empted
□ Not performed
□ Refusal
□ Other, specify:
-31-