Cover Image
close this bookWhere There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)
close this folderChapter 4 - HOW TO TAKE CARE OF A SICK PERSON
View the document(introduction...)
View the documentThe Comfort of the Sick Person
View the documentSpecial Care for a Person Who Is Very Ill
View the documentLiquids
View the documentFood
View the documentCleanliness and Changing Position in Bed
View the documentWatching for Changes
View the documentSigns of Dangerous Illness
View the documentWhen and How to Look for Medical Help
View the documentWhat to Tell the Health Worker
View the documentPatient Report

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?
__________ 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: ______________

On the back of this form write any other information you think may be important.