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Enquiry form for COVID Homecare
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* Indicates required question
Name of Patient:
*
Your answer
Patient's Phone No.
*
Your answer
Patient's Email
*
Your answer
Age:
*
Your answer
Gender:
*
Female
Male
Contact Person's Name:
*
Your answer
Contact Person's Phone:
*
Your answer
Contact Person's Email
*
Your answer
Address:
*
Your answer
Date of first symptoms:
MM
/
DD
/
YYYY
Date of COVID positive report:
MM
/
DD
/
YYYY
Co morbidities, if any:
Your answer
Oxygen saturation without support:
*
Your answer
Oxygen saturation with support:
Your answer
Fever:
Your answer
Chest HRCT severity score, if done:
Your answer
Brief details of current symptoms/discomfort being faced:
Your answer
Type of help required:
Your answer
Reference, if any
Your answer
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