44 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:_ __________________________________________________________________