Pre - Patient Self-Screening Checklist Form
FORM TO BE FILLED IN CAPITAL LETTERS ONLY
Email address *
Consulting Doctor *
Patient Name *
Your answer
Date *
MM
/
DD
/
YYYY
Time *
Time
:
Father / Husband Name *
Your answer
Age *
Your answer
Sex *
Address *
Your answer
Do you have Cough or Fever or Breathing difficulty or sore throat *
Do you have any history of international travel in the last 14 days where (COVID-19) has been reported *
Did you visit any health care facility where patients positive for corona virus (COVID-19) are being treated *
Did you have any kind of contact with a patient who was tested positive with Corona virus (COVID-19) *
Did you come in contact with any person who has cough/cold/breathing difficulty along with atleast one of the following in the last 14 days *
History of travel to country/area where COVID-19 has been reported
Contact with a patient who is positive for corona virus (COVID-19)
Visited or works in a health care facility where patients with corona virus (COVID-19) disease are treated
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