Doctor Prescription Doctor Prescription Yes No

Follow Up Sample Yes No

Patient Id

SRF NO

Patient Name

Patient In Quarantine Facility :
YES NO

Mobile No

Mobile No Belongs to SELF FAMILY

Age

Date Of Birth

Gender Select Gender Male Female Other

Nationality

Village/Town

District

State

Patient Address

Pincode

Downloaded Arogya Setu App Yes NO

Aadhar No (For Indians)

Passport No (For Foreign Nationals)

Vaccine Yes NO

Collection Date

Sample Id

Specimen Type :
Throat Swap Nasal Swap BAL ETA Nasopharyngeal Swap

Covishield :
1^st Dose 2^nd Dose Booster Dose

Covaxin :
1^st Dose 2^nd Dose Booster Dose

Patient Category :
Symptomatic International Traveler in Last 14 Days
Symptomatic Contact Of Lab Confirmed Case
Symptomatic Healthcare Worker / Frontline Workers
Hospitalized SARI (Severe Acute Respiratory illness) Patient
A Symptomatic direct and high risk contact of lab confirmed class - Family member
A Symptomatic Healthcare Worker in contact with confirmed case without adequate protection
Symptomatic Influenza like illness (ILI) in Hospital Pregnant women in / near Labour
Symptomatic (ILI) amoung returness and migrants (With in 7 days of illness)
Symptomatic Influenza Like illness (ILI) Patient in Hotspot / Containment Zones
(Please Specify)* (Select "Other" only If the patient doesn't belong to category 1-8)

Symptoms :
Cough Breathlessness Sore Throat Diarrhea Nausea Chest pain Vomiting Haemoptysis Nasal Discharge Fever at evaluation Body ache Sputum Abdominal pain

Which is the above mentioned was first symptom :

Date of onset of first symptom

Pre Existing Medical Conditions :
Chronic Lung disease Chronic renal disease Malignancy Diabetes Heart disease Hypertension Chronic Liver disease

Immunocompromised conditons

Other Underlying conditions

Hospitalization Details :

Hospitalized YES NO

Hospital ID / Number

Hospitalization Date

Hospital State

Hospital District

Hospital Name

Referring Doctor Details :

Name of the Doctor

Doctor Mobile No

Doctor Email Id