Medical Data Collection Form

A case record for patients with a respiratory infection covering lab confirmation, symptoms, travel and exposures, chest imaging, treatments and final outcome. Built for hospital teams and epidemiological surveillance staff.

Use this template

In the Claude connectors directory

Page 1

Completed by

First Name

Last Name

Date completed

Patient ID number

Patient name

First Name

Last Name

Age

Sex

Female Male Intersex Prefer not to say

Address

Street Address

City

State / Province

ZIP / Postal Code

Specimen collection date

Laboratory confirmation date (results released)

Confirming laboratory

Assay used by the laboratory

Sequencing performed by the laboratory

Admission date (if applicable)

Discharge date

Days admitted

Date of death (if applicable)

Page 2

Estimated date of first symptom

Temperature on admission (°C)

Pregnancy

Yes No Not applicable

Trimester of pregnancy

First Second Third

Postpartum (under 6 weeks)

Yes No Not applicable

Chronic lung disease (please specify)

Did the patient travel abroad in the 14 days before symptoms began?

Yes No Unknown

Did the patient travel within the country in the 14 days before symptoms began?

Yes No Unknown

If not a local resident, did the patient travel to the reference area?

Yes No Unknown

Did the patient visit any healthcare facility in the 14 days before symptoms began?

Yes No Unknown

Please specify

Did the patient have close contact with someone with an acute respiratory infection in the prior 14 days?

Yes No Unknown

Respiratory infection contact in a healthcare setting

Yes No Unknown

Respiratory infection contact in the family

Yes No Unknown

Respiratory infection contact at work

Yes No Unknown

Respiratory infection contact elsewhere (specify)

Date of exposure to the respiratory infection contact

Did the patient have contact with probable or confirmed cases?

Yes No Unknown

Date of exposure to probable or confirmed case

Did the patient visit any live animal markets?

Yes No Unknown

Likely place of exposure to live animals (city or country)

Date of exposure to live animals

Date of exposure to probable or confirmed case (follow-up)

Did the patient visit any live animal markets? (follow-up)

Yes No Unknown

Likely place of exposure to live animals (follow-up)

Date of exposure to live animals (follow-up)

Page 4

Section

Page 5

Final diagnosis

Pneumonia Acute respiratory distress syndrome Upper respiratory infection Sepsis Other

Complications

Cause of death

Respiratory failure Cardiac cause Sepsis Multi-organ failure Not applicable

Page 6

Related templates

Browse all reports templates →

	Column 1	Column 2	Column 3
Row 1
Row 2

	Column 1	Column 2	Column 3
Row 1
Row 2

Medical Data Collection Form

Page 1

Page 2

Page 3

Page 4

Section

Section

Page 5

Page 6

Related templates