COVID19 SEROLOGYCAL INVESTIGATION QUESTIONNAIRE N | ||||||
1. Date ___ / ___ / 202__ | 2. Patient name | |||||
3. DOB ___ / ___ / _____ | 4. Gender (mark) ☐ male ☐ female | |||||
5. Address | 6. Phone number | |||||
7. Patient’s current status | ○ Unknown ○ Laboratory confirmed (PCR positive) ○ Laboratory non-confirmed (PCR negative) ○ Under investigation ○ Under treatment ○ Treated ○ Previously had symptoms ○ Other (please specify)____________________________ | |||||
8. If laboratory confirmed (PCR), please mention the confirmation date ___ / ___ / 202__ | ||||||
9. If patient was recovered, please provide date for negative PCR test ___ /___ / 202__ | ||||||
10. Did you have contact with confirmed case of coronavirus? | ☐ Yes | ☐ No | ☐ Unknown | |||
11. If yes, please provide the date of last contact ___ / ___ / 202__ | ||||||
12. Is the patient medical worker | ☐ Yes | ☐ No | ☐ Unknown | |||
During illness did patient have the following symptoms? | ||||||
13. Fever 38˚C and higher | ☐ Yes | ☐ No | ☐ Unknown | |||
14. Subjective fever feeling | ☐ Yes | ☐ No | ☐ Unknown | |||
15. Chills | ☐ Yes | ☐ No | ☐ Unknown | |||
16. Muscle pain/myalgia | ☐ Yes | ☐ No | ☐ Unknown | |||
17. Rhinorrhea | ☐ Yes | ☐ No | ☐ Unknown | |||
18. Sore throat | ☐ Yes | ☐ No | ☐ Unknown | |||
19. Cough (newly started of worsening of chronic cough) | ☐ Yes | ☐ No | ☐ Unknown | |||
20. Shortness of Breath | ☐ Yes | ☐ No | ☐ Unknown | |||
21. Nausea/vomiting | ☐ Yes | ☐ No | ☐ Unknown | |||
22. Headache | ☐ Yes | ☐ No | ☐ Unknown | |||
23. Abdominal pain | ☐ Yes | ☐ No | ☐ Unknown | |||
24. Diarrhea (≥3 loose/looser than normal stools/24hr period) | ☐ Yes | ☐ No | ☐ Unknown | |||
25. Loss of sense of taste or smell | ☐ Yes | ☐ No | ☐ Unknown | |||
26. Conjunctivitis | ☐ Yes | ☐ No | ☐ Unknown | |||
27. Other (please specify) | ||||||
28. Do you currently have symptoms? | ☐ Yes | ☐ No | ☐ Unknown | |||
29. If no, please provide the date of last symptoms ___ / ___ / 202__ | ||||||
30. Were you hospitalized? | ☐ Yes | ☐ No | ☐ Unknown | |||
If the answer is “no”, please go to the question 36 | ||||||
31. If yes, please provide the date of your hospitalization ___ / ___ / 202__ | ||||||
32. Were you diagnosed with pneumonia? | ☐ Yes | ☐ No | ☐ Unknown | |||