Covid19-Initial Assessment Form

• Demographic Details
  Full Name *  

  Mr. Ms./Mrs. Master

  Gender*  

  M

  F

  Age *        

  Days

  Mnth

  Yrs

  Cancel

  Continue
• Covid19-Initial Assessment Form
  Is RT PCR test done? *    

  Yes No Reports pending

  Detected?  

  Yes No

  E Gene  

  RdRp Gene  

  N Gene  

  Is CT chest done? *  

  Yes No

  CORADS Value  

  Smoking *  

  Never Reformed Current

  Existing Disease/Co-morbidity

  Diabetes? *  

  Yes No

  Blood Sugar  

  Hypertension? *  

  Yes No

  Cardiovascular Diseases? *  

  Yes No

  Asthma? *  

  Yes No

  Chronic Kidney Disease/CKD? *  

  Yes No

  Immunocompromised condition/drugs/malignancy *  

  Yes No

  Other Disease *  

  Yes No

  Disease  

  On Medication *  

  Yes No

  Recent Hospitalization in last one year? *  

  Yes No

  Reason *  

  Are you currently pregnant?  

  Yes No

  Vitals

  Height *  

  Cms

  Feet

  Inches

  Weight *  

  BMI *  

  Your Temperature?  

  SpO2(%) *    

  Respiratory Rate  

  Blood Pressure  

  L

  R

  Blood Pressure  

  L

  R

  Diastolic  

  Systolic Right  

  Diastolic Right  

  Pulse  

  SpO2 after 6 min walk test is    

  Current Symptoms

  On what date did Covid-like symptoms first appear? *  

  Have Fever? *  

  Yes No

  From Date *    

  Continuous coughing? *  

  Yes No

  From Date *    

  Difficulty breathing or shortness of breath? *  

  Yes No

  From Date *    

  Fatigue/Tiredness? *  

  Yes No

  From Date *    

  Joint or Muscle Pain? *  

  Yes No

  From Date *    

  Having Diarrhoea? *  

  Yes No

  From Date *    

  Persistent pain/pressure in the chest? *  

  Yes No

  From Date *    

  Loss of Taste? *  

  Yes No

  From Date *    

  Loss of Smell? *  

  Yes No

  From Date *    

  Mental confusion or inability to arouse? *  

  Yes No

  From Date *    

  Developing bluish discolorations of lips/face? *  

  Yes No

  From Date *    

  Rhinorrhea/running nose/cold? *  

  Yes No

  From Date *    

  Sensation of Vomiting/Vomiting *  

  Yes No

  From Date *    

  Sore throat? *  

  Yes No

  From Date *    

  Rashes on the skin *  

  Yes No

  Conjunctivitis *  

  Yes No

  Discolouration of fingers and skin *  

  Yes No

  Other Symptoms? *  

  Yes No

  Details *  

  From Date *    

  Vaccination Details

  How many COVID19 vaccine doses have you taken? *  

  None First dose only Second dose

  Date of Vaccination *  

  Cancel

  Submit