Covid19-Initial Assessment Form

• Demographic Details
  Full Name

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  • Mr.
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  • Master
  • Baby

  Mr. Ms./Mrs. Master Baby

  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

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• 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

  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

  Other Disease *

  Please Enter Other Disease

  Yes No

  Immunocompromised condition/drugs/malignancy *

  Please Enter Immunocompromised condition/drugs/malignancy

  Yes No

  Chronic Kidney Disease/CKD? *

  Please Enter Chronic Kidney Disease/CKD?

  Yes No

  Are you currently pregnant?

  Please Enter Are you currently pregnant?

  Yes No

  Vitals

  Height *  

  Cms

  Feet

  Inches

  BMI *

  Please Enter BMI

  Weight *

  Please Enter Weight

  Your Temperature?

  Please Enter Your Temperature?

  SpO2(%) *  

  Please Enter SpO2(%)

  Respiratory Rate

  Please Enter Respiratory Rate

  Systolic

  / Systolic BP must be greater than Diastolic BP or Value must be in 40 to 160.

  Diastolic

  Please Enter Diastolic

  Diastolic Right

  Please Enter Diastolic Right

  Systolic Right

  Please Enter Systolic 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

  Joint or Muscle Pain? *

  Please Enter Joint or Muscle Pain?

  Yes No

  From Date *  

  Please Enter From Date

  Having Diarrhoea? *

  Please Enter Having Diarrhoea?

  Yes No

  From Date *  

  Please Enter From Date

  Persistent pain/pressure in the chest? *

  Please Enter Persistent pain/pressure in the chest?

  Yes No

  From Date *  

  Please Enter From Date

  Loss of Taste? *

  Please Enter Loss of Taste?

  Yes No

  From Date *  

  Please Enter From Date

  Loss of Smell? *

  Please Enter Loss of Smell?

  Yes No

  From Date *  

  Please Enter From Date

  Mental confusion or inability to arouse? *

  Please Enter Mental confusion or inability to arouse?

  Yes No

  From Date *  

  Please Enter From Date

  Developing bluish discolorations of lips/face? *

  Please Enter Developing bluish discolorations of lips/face?

  Yes No

  From Date *  

  Please Enter From Date

  Rhinorrhea/running nose/cold? *

  Please Enter Rhinorrhea/running nose/cold?

  Yes No

  From Date *  

  Please Enter From Date

  Sensation of Vomiting/Vomiting *

  Please Enter Sensation of Vomiting/Vomiting

  Yes No

  From Date *  

  Please Enter From Date

  Sore throat? *

  Please Enter Sore throat?

  Yes No

  From Date *  

  Please Enter From Date

  Rashes on the skin *

  Please Enter Rashes on the skin

  Yes No

  Conjunctivitis *

  Please Enter Conjunctivitis

  Yes No

  Discolouration of fingers and skin *

  Please Enter Discolouration of fingers and skin

  Yes No

  Other Symptoms? *

  Please Enter Other Symptoms?

  Yes No

  Details *

  Please Enter Details

  From Date *  

  Please Enter From Date

  Vaccination Details *

  How many COVID19 vaccine doses have you taken? *

  Please Enter How many COVID19 vaccine doses have you taken?

  None First dose only second dose

  Date of Vaccination *

  Please Enter Date of Vaccination

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  Submit