COVID-19 Persons Under Monitoring: Questions for Orpheus



View the Oregon Health Authority’s interim investigative guidelines for COVID-19 here.Summary Case InformationDiseasePerson Under MonitoringRisk Level Choose a risk level. Status Under MonitoringDeceasedChoose an item.Onset Date of PUM caseMM/DD/YYYY Note: This can be entered as the beginning date of the monitoring period. PUM Information and DemographicsFull Name First Name Last Name Date of Birth MM/DD/YYYYSexChoose an item.Race and Ethnicity: Choose an item.OccupationClick or tap here to enter text.WorksiteClick or tap here to enter text.Phone 1(###)-###-####.Phone 2(###)-###-####.Street Address Line 1Click or tap here to enter text.Street Address Line 2Click or tap here to enter text.City Click or tap here to enter text.StateAAZip Code#####CountyChoose an item.PUM Risk QuestionsWas the PUM interviewed? Choose an item.Interview DateMM/DD/YYYYWho was interviewedChoose an item.Interviewed by:Click or tap here to enter text.Did the PUM have any travel to mainland China, excluding Hubei Province? Choose an item.Notes:Include notes and specific travel dates here.Did the PUM have any travel to Hubei Province, China? Choose an item.Notes:Include notes and specific travel dates here.Did the PUM travel with any family members to mainland China?Choose an item.Notes:Include notes and specific details of other travelers here.Please make sure that all family members are entered into Orpheus. Sometimes the DGMQ reports are not complete.Was the PUM an airline contact of a symptomatic, confirmed case while seated OUTSIDE 6 feet of the person?Choose an item.Notes:Include notes and specific flight details here.Was the PUM an airline contact of a symptomatic, confirmed case while seated within 6 feet of them? Choose an item.Notes:Include notes and specific flight details here.Does the PUM live in the same household as, is an intimate partner of, or provides care in a non-healthcare setting (such as a home) for a symptomatic, confirmed case? Choose an item.Notes:Include notes and specific details here.Does the PUM have close contact to a confirmed, symptomatic case? Choose an item.Notes:Include notes and specific details here.PUM Clinical Information: Initial interviewIs the PUM symptomatic?Choose an item.Date of symptom onsetMM/DD/YYYYIs the PUM a healthcare worker?Choose an item.Is the PUM hospitalized? Choose an item.SymptomsIndicate whether the following symptoms were experienced by this patient: ? Fever (>100.4 F)? Coryza ? Any cough ? Any sore throat? Dyspnea or shortness of breath? Pneumonia diagnosis ? ARDS ? Mechanical ventilation? Other: Please explainPUM: Monitoring Information (only if indicated by PUM’s risk level)First exposure date: MM/DD/YYYYLast exposure date: MM/DD/YYYYReason for monitoring: Choose an item.Monitoring: Day 1DateMM/DD/YYYYSymptoms: ? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 2DateMM/DD/YYYYSymptoms: ? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 3DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 4DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 5DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 6DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 7DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 8DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 9DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 10DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 11DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 12DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 13DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature.Monitoring: Day 14DateMM/DD/YYYYSymptoms:? No symptoms ? Fever ? Cough ? Fatigue ? Sore Throat? Shortness of breath ? Pneumonia ? Other: Please explainTemperature 1Enter temperature.Temperature 2Enter temperature. ................
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