Covid19-Initial Assessment Form

• Demographic Details
  Full Name *

  Enter First name

  Mr. Ms./Mrs. Master Baby

  Gender*

  Please Select Gender

  M

  F

  Age *

  Please Select Date of Birth

  Age must be greater than 0 and less than 125 Years

  Months must be less than 12

  Days must be less than 31

  Days

  Mnth

  Yrs

  Cancel

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

  Please Enter Is RT PCR test done?

  Yes No Reports pending

  Detected?

  Please Enter Detected?

  Yes No

  E Gene

  Please Enter E Gene

  RdRp Gene

  Please Enter RdRp Gene

  N Gene

  Please Enter N Gene

  Is CT chest done? *

  Please Enter Is CT chest done?

  Yes No

  CORADS Value

  Please Enter CORADS Value

  Smoking *

  Please Enter Smoking

  Never Reformed Current

  Existing Disease/Co-morbidity

  Diabetes? *

  Please Enter Diabetes?

  Yes No

  Blood Sugar

  Please Enter Blood Sugar

  Hypertension? *

  Please Enter Hypertension?

  Yes No

  Cardiovascular Diseases? *

  Please Enter Cardiovascular Diseases?

  Yes No

  Asthma? *

  Please Enter Asthma?

  Yes No

  Chronic Kidney Disease/CKD? *

  Please Enter Chronic Kidney Disease/CKD?

  Yes No

  Immunocompromised condition/drugs/malignancy *

  Please Enter Immunocompromised condition/drugs/malignancy

  Yes No

  Other Disease *

  Please Enter Other Disease

  Yes No

  Disease

  Please Enter Disease

  On Medication *

  Please Enter On Medication

  Yes No

  Recent Hospitalization in last one year? *

  Please Enter Recent Hospitalization in last one year?

  Yes No

  Reason *

  Please Enter Reason

  Are you currently pregnant?

  Please Enter Are you currently pregnant?

  Yes No

  Vitals

  Height *

  Please Enter height in feet and inches

  Cms

  Feet

  Inches

  Weight *

  Please Enter Weight

  BMI *

  Please Enter BMI

  Your Temperature?

  Please Enter Your Temperature?

  SpO2(%) *  

  Please Enter SpO2(%)

  Respiratory Rate

  Please Enter Respiratory Rate

  Blood Pressure

  Please Select Blood Pressure and Enter Systolic and Diastolic value

  L

  R

  Blood Pressure

  Please Enter Systolic and Diastolic value

  L

  R

  Diastolic

  Please Enter Diastolic

  Systolic Right

  Please Enter Systolic Right

  Diastolic Right

  Please Enter Diastolic Right

  Pulse

  Please Enter Pulse

  SpO2 after 6 min walk test is  

  Please Enter SpO2 after 6 min walk test is

  Current Symptoms

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

  Please Enter On what date did Covid-like symptoms first appear?

  Have Fever? *

  Please Enter Have Fever?

  Yes No

  From Date *  

  Please Enter From Date

  Continuous coughing? *

  Please Enter Continuous coughing?

  Yes No

  From Date *  

  Please Enter From Date

  Difficulty breathing or shortness of breath? *

  Please Enter Difficulty breathing or shortness of breath?

  Yes No

  From Date *  

  Please Enter From Date

  Fatigue/Tiredness? *

  Please Enter Fatigue/Tiredness?

  Yes No

  From Date *  

  Please Enter From Date