serial number
Age
1. Are you here for follow-up?
2.Is one of the reasons that you are here that you are having difficulty with breathing?
3. Is one of the reasons that you are here that you are having cough for more than two weeks?
5. Is one of the reasons that you are here that you are having fever?
6. Total Score
7. Indicate sum of score
code of the facility
Date of visit
Patient's name
Patient's age
Patient's sex
Patient's inclusion number
Name of head household
Ward number
Interviewer's name
Interview time
5. Health Worker's name
6. Health Worker's sex
7. Designation
8. If other in 7
9. training of health worker in PAL
10. Consultantion starts at
11.Age
12. Pregnancy, if woman of child bearing age
13. Patient's problem
14. Cough and/or difficult breathing
15. Fever
16. Duration of cough
17. Duration of difficult breathing
18. Chest pain
19. Heamoptysis
20. If yes, how much
21. Smoking
22. If smoking, lost weight recently
23. Asthma
24. COPD
25. Heart Failure
26. TB
27. If TB, treatment card
28. Types of medication in the previous 24 hours
29. Episode occurs with exercise
30.Has sputum increased
31. Has sputum colour changed to yellow or green
Your own health state today (score)
7. Peak-flow measurement (l/min)
Tuberculosis