Health Care Seeking Behaviour and Treatment Result for Human African

Trypanosomiasis in East Kasai and Bandundu Provinces, in DRC

PART A : TO BE COMPLETED AT THE PNLTHA PROVINCIAL COORDINATION

Instruction : give check for correct selection in check box .

1. Name of patient : ...............................

2. Initials : ...............................
3. Sex : Male Famale
4. Age of Patient : .........years .........months ..........days
5. Address : ............................... City :................
6. Name of HAT treatment facility : ...................................
7. Distance to neurest PHC facility from village of patient : ............Km
8. Distance of HAT treatment facility from village of patient : ............Km
9. Information on latest round of active screening in the patient’s village of recidence :
9.1. Village ever screened : Yes No
9.2. Starting date : ......./......./..........(dd/mm/yyyy)
9.3. Parcitipation Rate : ..............times
9.4. Did the patient participate : Yes No
10. Mode of detection :
Detected by mobile team
Diagnosed at fixed HAT facility, referred by PHC
Diagnosed at fixed HAT facility, self-referral
Diagnosed at PHC facility
Other
(Specify)......................................
11. Date of HAT diagnosis : ......./......./..........(dd/mm/yyyy)
12. Date of start of HAT treatment : ......./......./..........(dd/mm/yyyy)
13. Physical exam at time of diagnosis :
Body temperature : ...... ̊C
Heart rate : .......times/minute
Blood pressure : Syst : .......mmHg
Distolic : .......mmHg
14. Signs/symptoms at time of diagnosis (able to choose more than one (√))
None
Fever
Headache
Pain in other body parts
Swollen glands
Itching
Psychological
Other
(Specify)......................................
15. Diagnostic criteria
15.1. Pracitologicaly confirmed? Yes No
15.2. Test results
Test: Positive Negative ND
Catt whole blood
Catt dilation, indicate and titre : ...........
Thick film
Gland puncture
Woo
Macct
Lumbar puncture (Trypanosomes)
Lumbar puncture (>5 cells)
Other, specify