(Attachment 1)

Novel Coronavirus Infection (including suspected cases)
Basic Information/Clinical iInformation Survey Form
Basic information*Survey conducted byID
Public Health Center

1

Name of investigator:
Method: □ Interview □ Telephone □ Other (Date and time of the survey:
2

Respondent: □ Patient □ Not patient → Name () relationship (Contact info of the respondent: Home phone:--))Mobile:--3

Diagnostic category: Novel coronavirus infection (patient (confirmed case) / asymptomatic carrier / suspected case)

4NESID registration ID:

5

Patient's local public health center:

6

Name of reporting medical institution:

7

Name of attending physician:

8Institution address:

9

Institution phone number :10

Report received on (date):

11

Report received by (municipality):

12

Report received by :13

Report received by (name of person):

14

Date of patient's first visit to the medical institution:

15

Date of diagnosis:

16

Estimated date of infection:

17

Date of onset:

Pubic Health Center* Entries to 3-17 should be transcribed from the Outbreak Reporting Form. (Column 4 is entered after the case is registred in NESID)
18

Patient name:

19 Male / Female

21Nationality:

22 Patient address

Patient's phone number: Home-

23, Mobile, years and-months old-

＠Patient's Email address:
24-

20 Date of birth:

When surveyed, the patient was mainly at: □medical institution □home □work place/school □others (Contact address:

phone number:-) □unknown-Occupation / business type / school (including kindergarten, nursery, etc.):
Last attended on (Date):
25

Company/school name:Company/school address:
Company/school phone number:
Other contact information (of guardian, etc.)

26Name:Relationship with the patient:Address:
Phone number

Home:--Mobile:--Pregnancy

no / yes(th week of pregnancy)

Smokingno / yes(started at the age of,cigarettes/day)Diabetesno / yes

Respiratory disease (asthma, COPD, others)

no / yes(details:

Kidney diseaseno / yes(if yes, hemodialysis?

Liver diseaseno / yes(details:)

Heart diseaseno / yes(details:)

Neuromuscular diseaseno / yes(details:)

no / yes(details:)

Immunodeficiency (HIV, use of immunosuppressant)no / yes(details:)

Maligunant tumor (cancer)(details:)

Blood disease (anemia and others)

Others (no / yes))

yes / no)Clinical courses

ID

Symptoms * enter other information including the presence of symptoms, body temperature, time, etc., as required
Date///////

coughno / yesno / yesno / yesno / yesno / yesno / yesno / yesdifficulty breathing

no / yesno / yesno / yesno / yesno / yesno / yesno / yesnasal
discharge/congestion

no / yesno / yesno / yesno / yesno / yesno / yesno / yesOthers

Resp. sympt.

Symptoms
max. body temp. (℃)

sore throat

no / yesno / yesno / yesno / yesno / yesno / yesno / yesnausea/vomiting

no / yesno / yesno / yesno / yesno / yesno / yesno / yes

conjunctival hyperemia

no / yesno / yesno / yesno / yesno / yesno / yesno / yesheadacheno / yesno / yesno / yesno / yesno / yesno / yesno / yesgeneral malaiseno / yesno / yesno / yesno / yesno / yesno / yesno / yesarthralgia/myalgia

no / yesno / yesno / yesno / yesno / yesno / yesno / yes

diarrheano / yesno / yesno / yesno / yesno / yesno / yesno / yesdisturbed
consciousness

no / yesno / yesno / yesno / yesno / yesno / yesno / yes

convulsions

no / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yes///////

coughno / yesno / yesno / yesno / yesno / yesno / yesno / yesdifficulty breathing

no / yesno / yesno / yesno / yesno / yesno / yesno / yesnasal
discharge/congestion

no / yesno / yesno / yesno / yesno / yesno / yesno / yessore throat

no / yesno / yesno / yesno / yesno / yesno / yesno / yesothers28()
Date

OthersResp. sympt.

Symptoms
max. body temp. (℃)

nausea/vomiting

no / yesno / yesno / yesno / yesno / yesno / yesno / yesconjunctival hyperemia

no / yesno / yesno / yesno / yesno / yesno / yesno / yesheadacheno / yesno / yesno / yesno / yesno / yesno / yesno / yesgeneral malaiseno / yesno / yesno / yesno / yesno / yesno / yesno / yesarthralgia/myalgia

no / yesno / yesno / yesno / yesno / yesno / yesno / yes

diarrheano / yesno / yesno / yesno / yesno / yesno / yesno / yesdisturbed
consciousness

no / yesno / yesno / yesno / yesno / yesno / yesno / yes

convulsions

no / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesno / yesothers(293031)

Time and date of onset (through the interview):
Detected because this case was:
□ a reported case of novel coronavirus infection(category: patient (confirmed case), asymptomatic carrier, suspected case, others)□ contact person under health obeservation (confirmed case ID:
name:□ others (Clinical course or treatments received before the diagnosis or other noteworthy things:)
)

ID

32

Hospitalization: □ no □ yes (if yes, period of hospitalization: fromuntil

Name of medical institution:

Attending doctor's name:

Department:)

Designated medical institution to report severe infectious disease cases of unknown etiology? Yes / No
Address of the medical institution:
33

Chest X ray: No / Yes (findings:34

Chest CT: No / Yes (findings:35

Use of mechanical ventilator: No / YesContact:))

Medical treatment after the first visit
Date36

Med. inst. name Medical treatment

Notes (Results of tests/treatments, etc.)///37

Outcome: Discharged (dateOther notes in clinical course:) , Death (date)38

Test results
Tests for novel coronavirus
Specimen type

Results

Sampling date39

Test method- / + / others ()- / + / others ()- / + / others ()- / + / others ()- / + / others ()Test facility

Other tests
Specimen
Sampling datetype

PathogenResults

Method Test facility●Culture test: No / Yes / unknown
If yes- / + (bacterium:)- / + (bacterium:)- / + (bacterium:)- / + (bacterium:)●Antibody test: No / Yes / unknown
40

Influenza virus-/+

RS virus-/+Adenovirus-/+

Pneumococcus-/+

Legionella-/+●Other test methods
Pathogen ()Pathogen ()- / + / others ())- / + / others ()Pathogen (Any additional comments- / + / others ()