COVID Suspected Patient Intake Form

Please fill out the form

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Step 5

Personal Information

Full Name:

First Name

Last Name

Date of Birth:

Gender:

Male
Female

Email Id:

Mobile No:

Address:

Address Line1

Address Line2

Land Mark

City

State

Country

Zip Code

Emergency Contact

Name:

First Name

Last Name

Relationship:

Email Id:

Mobile No:

Address:

Address Line1

Address Line2

Land Mark

City

State

Country

Zip Code

COVID-19 Questionnaire

Please list down your travel history for last 1 month:

If you have travelled in the last 1 month, please list down people you have contacted:

Please list down all your connections that have visited a foreign country in the last 1 month:

Please list out your household:

Please check the symptoms that apply:

High fever
Cough
Difficulty in breathing
Persistent pain or pressure in the chest
Body aches
Nasal congestion
Runny nose
Sore throat

Actions

This area will be filled out by the health personnel

Observations and Further Actions to be taken:

Health Personnel Name:

First Name

Last Name

Date:

Time:

Signature:

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Personal Information

Emergency Contact

Health and Medical History

COVID-19 Questionnaire

Actions