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