Coronavirus Suspected Patient Intake Form
Personal Information
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Gender
Male
Female
National Security Number
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
First Name
Last Name
Relationship
Contact Number
Email
example@example.com
Address
Health and Medical History
Please check all that apply
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Epilepsy Seizures
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Hepatitis
Kidney Disease
Liver Dİsease
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Dİsorders
Lung Disease (Chronic Obstructive Pulmonary Disease)
Other
Please list any allergies
Please list your current medications
Please list any operations and dates of each
Please type down family medical history
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Do you have any risk of being pregnant?
Yes
No
COVID-19 Questionnaire
Please list down your travel history for last 1 month
If you have travelled in the last 1 month, please list down people you have contacted
Name / Age / Contact Information
Please list down all your connections that have visited a foreign country in the last 1 month
Please list out your household
Please check the symptoms that apply
High fever
Cough
Difficulty in breathing
Persistent pain or pressure in the chest
Body aches
Nasal congestion
Runny nose
Sore throat
Diarrhea
Other
Actions
This area will be filled out by the health personnel
Observations and Further Actions to be taken
Health Personnel Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
Submit
Should be Empty: