Location: Preferred Collection Date* Preferred Collection Time*

Google Map: Click Here to Get Direction

Doctor Prescription: Yes No

Repeat Sample: Yes No

If Yes, Patient ID*

Patient Name*

Gender of Patient* Male Female Other

Email*

Present Village or Town*

District of Present Residence*

State of Present Residence* Delhi (NCR)

Passport No. (For Foreign Nationals):

Aadhar No. (For Indians)

Nationality

Downloaded Aarogya Setu App Yes No

PIN*

Specimen type

BAL/ETA

TS/NPS/NS

Blood in EDTA

Acute Sera

Covalescent sera

Other

Label

PATIENT CATEGORY Cat 1: Symptomatic international traveller in last 14 Days Cat 2: Symptomatic contact of lab confirmed case Cat 3: Symptomatic healthcare worker Cat 4: Hospitalized SARI (Severe Acute Respiratory Illness) patient Cat 5a: Asymptomatic direct and high risk contact of lab confirmed case Cat 5b: Asymptomatic healthcare worker in contact with confirmed case without adequate protection Cat 6: Symptomatic Influenza Like Illness (ILI) patient in hospital/MoHFW identified clusters Others

Details

Respiratory infection: Severe Acute Respiratory Illness (SARI): Yes No

Influenza Like Illness Yes No

1. Did you travel to foreign country in last 14 days: Yes No

If yes, place(s) of travel:

Stay/travel duration from:*

Stay/travel duration to:*

2. Have you been in contact with lab confirmed COVID-19 patient: Yes No

If yes, name of confirmed patient:

3. *Were you Quarantined?: Yes No

*If yes, where were you quarantined: Home Facility

4. Are you a health care worker working in hospital involved in managing patients: Yes No

Date of onset of symptoms:*

First Symptom:

Symptoms

Cough

Breathlessness

Sore throat

Sputum

Diarrhoea

Nausea

Chest pain

Abdominal pain

Vomiting

Haemoptysis

Nasal discharge

Fever at evaluation

Body ache

If Yes Date From:*

If Yes Date to:*

If Yes Date From:*

If Yes Date to:*

Condition

Chronic lung disease

Chronic renal disease

Malignancy

Diabetes

Heart disease

Hypertension

Chronic liver disease

Immunocompromised condition: Yes No

Other underlying conditions:

Hospitalized: Yes No

Hospitalization Date:*

Hospital State:

Hospital District:

Hospital Name:

Name of Doctor:

Doctor Mobile No.:

Doctor Email ID:

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