Coronavirus disease (COVID-19) technical guidance by WHO Household transmission investigation protocol | Page 34

6b. Respiratory symptoms
Sore throat
□ Yes □ No □ Unknown
If Yes, date ___/___/___
Runny nose □ Yes □ No □ Unknown
Cough □ Yes □ No □ Unknown
If Yes, date ___/___/___
Shortness of breath □ Yes □ No □ Unknown
If Yes, date ___/___/___
6c. Other symptoms
Chills
Vomiting
Nausea
Diarrhoea
Headache
Rash
Conjunctivitis
Muscle aches
Joint ache
Loss of appetite
Nose bleed
Fatigue
Seizures
Altered consciousness
Other neurological signs
Other symptoms
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
If Yes, specify:
□ Yes □ No □ Unknown
If Yes, specify:
7. Outcome (Day 1)
Outcome
□ Alive □ Dead □ na □ Unknown
Outcome current as of date (dd/mm/yyyy)
___/___/___
□ Unknown □ na
□ Yes □ No □ Unknown
Hospitalization
If Yes, date of first hospitalization (dd/mm/yyyy)
___/___/___
□ Unknown
If Yes, specify reason for hospitalization:
8. Contact 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
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