WHO Minimum Clinical Data Set for H5N1 Patients- Page 1 Date of report(day-mont -year!

" Unique Patient Number: Presentation Date of illness onset (day-month-year): nitial sym!toms: "e#er $%&o' (yes/no) Sore throat (yes/no) 'ough (yes/no) (eada)he (yes/no) Diarrhoea (yes/no) *omiting (yes/no) A!!etite loss (yes/no) +alaise (yes/no) ,oint !ain (yes/no) Date of initial out!atient e#aluation (day-month-year): +anifestations: "e#er (yes/no) Sore throat (yes/no) 'ough (yes/no) Shortness of breath (yes/no) Diarrhoea (yes/no) *omiting (yes/no) -em!erature (o'): Pulse (/min): .es!irations (/min): Age (years): Sex (male/female):

Hospitali#ation (yes$no! Date of hos!itali/ation (day-month-year): +anifestations: "e#er $%&o' (yes/no) Sore throat (yes/no) 'ough (yes/no) Shortness of breath (yes/no) 'hest !ain (yes/no) S!utum !rodu)tion (yes/no) 0loody s!utum (yes/no) Diarrhoea (yes/no) *omiting (yes/no) Abdominal !ain (yes/no) Altered mental status (yes/no) -em!erature (o'): Pulse (/min): .es!irations (/min): Sa12 (3) on room air: Platelet

Date of initial laboratory testing (day-month-year): 40' (no5/mm%) P+N (3) 6ym!ho)yte (3) (no5/mm%) ASA6'reatinine

(aemoglobin (mg/dl)

S!utum 7ram stain (des)ribe): S!utum )ulture (negati#e/!ositi#e/not done): 0lood )ulture (negati#e/!ositi#e/not done): 'hest radiogra!h: infiltrates (yes/no) (unilateral/bilateral) !leural effusion (yes/no) f diarrhoea8 stool o))ult blood (yes/no)8 stool 40' (yes/no) Pre-existing )onditions: Pregnan)y (yes/no) (eart disease (yes/no) 6ung disease (yes/no) Diabetes (yes/no) mmune defi)ien)y state (yes/no) Des)ribe:

WHO Minimum Clinical Data Set for H5N1 Patients- Page % Date of report(day-mont -year!" Unique Patient Number: Clinical course &reatments gi'en" (nfluen#a-specific anti'iral medication (yes) no! Oseltami'ir (yes) no! Drug 1seltami#ir :anami#ir Amantadine/ rimantadine .iba#irin 'orti)osteroids S!e)ify: Antibioti) treatment (yes/no) 6ist agents: 'orti)osteroid treatment (yes/no): S!e)ify ty!e8 dose8 duration: Su!!lemental oxygen thera!y (yes/no) Duration of su!!lemental oxygen thera!y (days): ntubation/me)hani)al #entilation (yes/no) Date of intubation/me)hani)al #entilation (day-month-year): Date of extubation (day-month-year): Duration of intubation (days): Duration of su!!lemental oxygen thera!y (days): Secondary complications" *'ent 0a)teraemia 0a)terial !neumonia +es$No Date of onset (day-mo-year! Duration (days! (llness onset to start (days! Date of start (day-mo-year! Dose (mg$day! and route Date of stop (day-mo-year! Age (years): Sex (male/female):

*entilator-asso)iated !neumonia (y!otension .enal failure 'oagulo!athy 1ther (des)ribe): WHO Minimum Clinical Data Set for H5N1 Patients- Page , Date of report(day-mont -year!" Unique Patient Number: Outcome (reco'ery$deat !" Duration of hos!itali/ation (days): Date of hos!ital dis)harge (day-month-year): Date of death (day-month-year): Post-mortem obtained (yes/no): Age (years): Sex (male/female):