ICMR Specimen Referral Form for COVID-19 (SARS-CoV2)
Email address *
Please select your required Test *
Required
SECTION A – MANDATORY FIELDS (FORM WILL NOT BE ACCEPTED IN CASE OF ANY BLANK)
A.1 Person details
Patient Name *
Age *
Gender *
Present Village or Town *
District of present residence *
Nationality *
State of present residence *
Mobile number *
Mobile number belongs to *
A.3 PATIENT CATEGORY (PLEASE SELECT ONLY ONE) *
B.1 PERSON DETAILS
Present patient address
Pin code
Date of Birth
MM
/
DD
/
YYYY
Email id
Patient Passport Number
Patient Aadhar No
B.2 EXPOSURE HISTORY(2 WEEKS BEFORE THE ONSET OF SYMPTOMS)
B.2.1. Did you travel to foreign country in last 14 days:
Clear selection
If yes , place(s) of travel
Stay/travel duration: Fr Date and To date
Clear selection
B.2.2. Have you been in contact with lab confirmed COVID-19 patient:
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If Yes Name of the confirmed patient
B.2.3. Were you Quarantined?:
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If yes, where were you quarantined
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3.2.4. Are you a health care worker working in hospital involved in managing patients
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B.3 CLINICAL SYMPTOMS AND SIGNS
Date of onset of symptoms
MM
/
DD
/
YYYY
First symptom
Symptoms
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Any symptoms If yes; From Date ,To date and History
Respiratory infection at sample collection:Severe Acute Respiratory Illness (SARI)
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ARI
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B.4 UNDERLYING MEDICAL CONDITIONS
Please select
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IMMUNOCOMPROMISED CONDITION: Yes/No
Other underlying conditions:
B.5 HOSPITALIZATION, TREATMENT AND INVESTIGATION
Hospitalization date AND Out come date
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ETIOLOGY IDENTIFIED
ATYPICAL PRESENTATION
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ETIOLOGY IDENTIFIED
UNUSUAL / UNEXPECTED COURSE
Clear selection
OUTCOME: Discharge/Death/
Hospital Name/address
Name of Doctor
DETAILS OF HEALTH AUTHORITY (FOR SENDING THE REPORT)
Name of Doctor
Hospital Name /address
EMAIL ID
Phone /mobile number
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