COVID-19 Triage Form
Name
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Insurance No.
Are you a frontline worker during this pandemic? (Police, Fireman, Nurse, Physician, etc.)
Yes
No
Current Temperature °C
Is it more than 37.8°C?
Yes
No
Does your temperature goes down if you drink a medicine like paracetamol?
Yes
No
Does your temperature goes down if you drink a medicine like paracetamol?
Yes
No
How long do you have this fever? (Hours/Days)
Are you coughing?
Yes
No
Does it have a sputum?
Yes
No
What is the color of the sputum?
How long do you have this cough? (Hours/Days)
Are you having difficulty of breathing?
Yes
No
Are you having difficulty of breathing while
Sitting
Resting
Lying down
Walking
How long have you been experiencing this breathing issues? (Hours/Days)
Do you feel weak and tired?
Yes
No
How long have you been feeling this way? (Hours/Days)
Are you having headaches?
Yes
No
When did the headaches started? (Hours/Days)
Are you having abdominal problems?
Yes
No
When did the abdominal problems started? (Hours/Days)
Have you loss your sense of smell and taste?
Yes
No
When did you start losing your sense of smell and taste? (Hours/Days)
Do you have a sore throat?
Yes
No
When did you sore throat started? (Hours/Days)
Have you made a close contact with any COVID-19 positive/suspected cases or people in the last 14 days without wearing PPE?
Yes
No
Have you travel to a country that has COVID-19 community transmission?
Yes
No
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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