SAMAL RURAL HEALTH UNIT

NAME OF INVESTIGATOR M-JAY T. VINZON

DATE OF INTERVIEW 08/05/21
SYMPTOMS N/A
LAST NAME: VILLANUEVA
FIRST NAME CATALINA
MIDDLE NAME: SALDAÑA BIRTHDAY
BIRTHDAY 9/21/1953 0 9 2 1 1 9 5 3
AGE 67 SWAB PLACE
HOUSE NUMBER LOT 6 BLOCK 6 SAMAL MARKET
STREET STA. CATALINA HOMES
BARANGAY TABING ILOG
MUNICIPALITY SAMAL ZIP CODE 2113
PROVINCE BATAAN
REGION III
HOME PHONE NUMBER N/A
CELLPHONE NUMBER 9393661463
OCCUPATION -
CIVIL STATUS WIDOW
NATIONALITY FILIPINO
PASSPORT N/A
EMAIL ADDRESS N/A
ADDRESS OUTSIDE PH N/A
IF NONE
IF YES
TYPE MANUALLY

PHILHEALTH NUMBER 70504931720 0 7 0 2 5 6 0 3 2 7 2 2

MAIDEN NAME PHILHEALTH MEMBER
LAST TIANGCO LAST NAME: VILLANUEVA
FIRST ROSITA FIRST NAME: CATALINA
MIDDLE / MIDDLE NAME: SALDAÑA
SPOUSE IF MARRIED FLORICEL - SALDAÑA
PLACE OF BIRTH SAMAL, BATAAN
-
INCOME -
PROOF OF INCOME -
-
NAME OF WORK PLACE N/A
LOT/BLDG -
STREET N/A

ST/BRGY POBLACION
MUNICIPALITY BALANGA
PROVINCE BATAAN
INDEX NONE
LDE NONE
SWABDATE: 8/6/2021
 SUMANDAL JUDIEL MAGPOC Iii Samal Bataan San juan 158 kabuhayan st. 06/30/2001 19 M 09318554543 None

SINGLE
MARRIED
WIDOW

VILLANUEVA
CATALINA
SALDAÑA
SALDAÑA
19 M 09318554543 None filipino N Single None None A+
 0 7 0 2 5 6 0 3 2 7 2 2

I. PERSONAL DETAILS
LAST NAME FIRST NAME NAME
EXTENSION MIDDLE NAME NO MIDDLE
NAME
MONONYM
li cable only)
(Check i f app
(Jr./Sr./III)

MEMBER
VILLANUEVA CATALINA SALDAÑA
MOTHER’s
MAIDEN NAME TIANGCO ROSITA /
SPOUSE
(If Married) FLORICEL - SALDAÑA
DATE OF BIRTH PLACE OF BIRTH (City/Municipality/Province/Country) (Please
indicate country if born outside the Philippines)
0 9 2 1 1 9 5 3 SAMAL, BATAAN
m m d d y y y y

II. ADDRESS and CONTACT DETAILS

PERMANENT HOME ADDRESS
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name

LOT 6 BLOCK 6 STA. CATALINA HOMES

Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP Code

TABING ILOG SAMAL BATAAN 2113

MAILING ADDRESS o
SAME AS ABOVE
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name

Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP Code

III. DECLARATION OF DEPENDENTS

NAME DATE OF BIRTH Check
FIRST EXTENSION (mm-dd-yyyy) NO MIDDLE if with
MONO

LAST NAME (Jr./Sr./III)

MIDDLE NAME RELATIONSHIP CITIZENSHIP
NAME Perma
NYM

NAME nent
Disabi
CHECK IF APPLICABLE lity

IV. MEMBER TYPE

PROFESSION: (Except Employed, Lifetime Members and

MONTHLY INCOME: PROOF OF INCOME:
Sea-based Migrant Worker)

- - -
This form may be reproduced and is not for sale Continue at the back
 Philippine Integrated
Disease Surveillance and Case Investigation Form
Response Coronavirus Disease (COVID-19)
Version 9
1) The Case Investigation Form (CIF) is meant to be administered as an interview by a health care worker or any personnel of the DRU. This is not a self-administered questionnaire.
2) Please be advised that DRUs are only allowed to obtain 1 copy of accomplished CIF from a patient.
3) Please fill out all blanks and put a check mark on the appropriate box. Never leave an item blank (write N/A). Items with * are required fields. All dates must be in MM/DD/YYYY format.
Disease Reporting Unit* DRU Region and Province PhilHealth No.*

SAMAL RURAL HEALTH UNIT REGION III, BATAAN 70504931720

Name of Interviewer Contact Number of Interviewer Date of Interview (MM/DD/YYYY)*

M-JAY T. VINZON 9687241085 8/5/2021

Name of Informant (if applicable) Relationship Contact Number of Informant

N/A N/A N/A

Not applicable (New case) Update outcome Update disposition
Not applicable (Unknown) Update case classification Update exposure / travel history
If existing case Update symptoms Update lab result Others, specify:
(check all that apply)* Update health status Update chest imaging findings

Type of Client COVID-19 Case (Suspect, Probable, or Confirmed)  Close Contact For RT-PCR Testing (Not a Case of Close Contact)
Testing Category/Subgroup (Check all that apply, refer to Appendix 2)  A  B   D  E    H  I  J
C F G

Part 1. Patient Information

1.1. Patient Profile
Last Name* VILLANUEVA First Name (and Suffix)* CATALINA Middle Name* SALDAÑA
Birthday (MM/DD/YYYY)* 9/21/1953 Age* 67 Sex* Male Female
Civil Status WIDOW Nationality* FILIPINO
Occupation - Works in a closed setting?  Yes  No  Unknown
1.2. Current Address in the Philippines and Contact Information* (Provide address of institution if patient lives in closed settings, see 1.5)
House No./Lot/Bldg.* Street/Purok/Sitio* Barangay* Municipality/City*

LOT 6 BLOCK 6 STA. CATALINA HOMES TABING ILOG SAMAL

Province* Home Phone No. (& Area Code) Cellphone No.* Email Address

BATAAN N/A 9393661463 N/A

1.3. Permanent Address and Contact Information (if different from current address)
House No./Lot/Bldg. Street/Purok/Sitio Barangay Municipality/City

LOT 6 BLOCK 6 STA. CATALINA HOMES TABING ILOG SAMAL

Province Home Phone No. (& Area Code) Cellphone No. Email Address

BATAAN N/A 9393661463 N/A

1.4. Current Workplace Address and Contact Information
Lot/Bldg. Street Barangay Municipality/City

- N/A POBLACION BALANGA

Province Name of Workplace Phone No./Cellphone No. Email Address

BATAAN N/A 9393661463 N/A

1.5. Special Population (indicate further details on exposure and travel history in Part 3)
Health Care Worker* Yes, Name & location of health facility: No
Returning Overseas Filipino*  Yes, Country of origin:                                                            __ and Passport number:__________________________ No
_____OFW:  OFW  Non-OFW

Foreign National Traveler*  Yes, Country of origin:____________________________and Passport number:___________________________ No

Locally Stranded Individual / APOR /  Yes, City, Municipality, & Province of origin                                                                            No
Local Traveler*  Locally Stranded Individual  Authorized Person Outside Residence / Local Traveler

Lives in Closed Settings*  Yes, specify institution type:                                                             and name:                                                                   No
(e.g. prisons, residential facilities, retirement communities, care homes, camps, etc.)

Part 2. Case Investigation Details

2.1. Consultation Information
Have previous COVID-19 related consultation? Yes, Date of First Consult (MM/DD/YYYY)*                                             No
Name of facility where first consult was done
2.2. Disposition at Time of Report* (Provide name of hospital/isolation/quarantine facility)
 Admitted in hospital                                                                            Date and Time admitted in hospital ____________________________
 Admitted in isolation/quarantine facility                                        Date and Time isolated/quarantined in facility ___________________

 In home isolation/quarantine
_ Date and Time isolated/quarantined at home TABING-ILOG
____________________
 Discharged to home If discharged: Date of Discharge (MM/DD/YYYY)*
2.3. Health Status at Consult* (Refer to Appendix 3)  Asymptomatic  Mild  Moderate  Severe  Critical
2.4. Case Classification* (Refer to Appendix 1)  Suspect  Probable  Confirmed  Non-COVID-19 Case
2.5. Vaccination information*
Date of vaccination* Name of Vaccine* Dose number (e.g. 1st, 2nd)* Vaccination center/facility Region of health facility Adverse event/s?

N/A N/A N/A N/A N/A  Yes  No

 Yes  No
 Yes  No
 Yes  No
INDEX NONE
LDE NONE
SWABDATE 8/6/2021
POS SAMAL MARKET
 2.6. Clinical Information
Date of Onset of Illness (MM/DD/YYYY)* N/A Comorbidities (Check all that apply if present)
                                                        
Signs and Symptoms (Check all that apply)
 Asymptomatic  Dyspnea  None  Neurological Disease
 Fever                   °C  Anorexia  Gastrointestinal  Heart Disease
 Cough  Nausea  Hypertension  Cancer
 General weakness  Vomiting  Genito-urinary  Lung Disease
 Fatigue  Diarrhea  Diabetes  Others                                   
 Headache  Altered Mental Status
 Myalgia  Anosmia (loss of smell, w/o any identified cause) Pregnant?  Yes, LMP (MM/DD/YYYY)                                     No
 Sore throat  Ageusia (loss of taste, w/o any identified cause)
 Coryza  Others, specify                            High-risk pregnancy?  Yes  No
Was diagnosed to have Severe Acute Respiratory Illness?  Yes  No

Chest imaging findings suggestive of COVID-19

Date done Imaging done Results

N/A  Chest radiography  Normal  Chest radiography: Hazy opacities, often rounded in morphology, with peripheral and lower lung dist.
 Chest CT  Pending  Chest CT: Multiple bilateral ground glass opacities, often rounded in morphology, w/ peripheral & lower lung dist.
 Lung ultrasound  Lung ultrasound: Thickened pleural lines, B lines, consolidative patterns with or without air bronchograms
 None  Other findings, specify                                                                                                                  

2.7. Laboratory Information

Have tested positive using RT-  Yes, date of specimen Collection (MM/DD/YYYY)*                                                
PCR before? *
Laboratory* No. of previous RT-PCR swabs done      
Date collected* Date released Laboratory* Type of test* Results*
 RT-PCR (OPS)  Antigen test; Provide reason below:  Pending  Negative
 RT-PCR (NPS)                                                         Positive  Equivocal
 RT-PCR (OPS and NPS)  Antibody test  Others:
8/6/2021 8/6/2021 BGHMC-PCR LAB  Others:
 RT-PCR (OPS)  Antigen test; Provide reason below:  Pending  Negative
 RT-PCR (NPS)                                                         Positive  Equivocal
 RT-PCR  Antibody test 
 Others: (OPS and NPS)
                                                                                              Others:
2.8. Outcome/Condition at Time of Report*
 Active (currently admitted/isolation/quarantine)  Recovered, date of recovery (MM/DD/YYYY)*                               Died, date of death (MM/DD/YYYY)*                                
If died, Immediate Cause: Antecedent Cause:
cause of death*
Underlying Cause: Contributory Conditions:
PART 3. Contact Tracing: Exposure and Travel History
History of exposure to known probable and/or confirmed COVID-19 case 14 days before the onset  Yes, date of last contact (MM/DD/YYYY)*                                
of signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection? *
 No  Unknown

Has the patient been in a place with a known COVID-19 transmission 14 days before the onset of  Yes, International  Yes, Local
signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection? *
 No  Unknown exposure

If International Travel, Inclusive travel dates: From: To:

country of origin
N/A With ongoing COVID-19 community transmission?  Yes  No

Airline/Sea vessel Flight/Vessel Number Date of departure (MM/DD/YYYY) Date of arrival in PH (MM/DD/YYYY)

N/A N/A N/a N/A

If Local Travel, specify travel places (Check all that apply, provide name of facility, address, and inclusive travel dates in MM/DD/YYYY)
Place Visited Name of Place Address Inclusive Travel Dates With ongoing COVID-19
(Region, Province, Municipality/City) Community Transmission?
From: To:

 Health Facility  Yes  No

 Closed Settings  Yes  No
 School  Yes  No
 Workplace  Yes  No
 Market  Yes  No
 Social Gathering  Yes  No
 Others  Yes  No
 Transport Service, specify the following:
] Flight / Vessel / Bus No. Place of Origin Departure Date (MM/DD/YYYY) Destination Date of Arrival (MM/DD/YYYY)

N/A N/A N/A N/A N/A N/A

- If symptomatic, provide names and contact numbers of persons who were with Name (Use the back page if needed) Contact Number
the patient two days prior to onset of illness until this date
- If asymptomatic, provide names and contact numbers of persons who were with
the patient on the day specimen was submitted for testing until this date
                                                              

                                             
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