No.: Patient name: number: up researcher:

Current symptoms

1) Fever (temperature) 2) Breathing difficulty 3) Cough 4) Expectoration 5) Chest distress 6) Shortness of breath 7) Debilitation 8) Others

Sleep

1) Good 2) Fair 3) Poor Influence factors:

Diet (appetite)

1) Good 2) Fair 3) Poor Influence factors:

Activities and psychology

Personal self-care condition: ADL scores

Exercise: 1) Yes, programs: a) square dancing b) gymnastics c) yoga d) taijiquan e) others

2) No Human Communication: Self-rating happiness scale Self-perceived burden scale

Hand hygiene

hand-washing method: 1) Seven-step hand-washing method 2) Washing time 3) Timing of washing hands

Use of disinfectants

1) Use and storage of alcohol 2) Use of chlorine-containing disinfectants 3) Disinfection of toilet 4) Floor drain treatment

Medication compliance

1) Regular 2) Intermittent 3) Non-drug

Adverse drug reaction

1) Yes 2) No

Implementation of isolation measures

1) Use of masks 2) Single private room 3) No optional outing 4) Table-ware disinfection or private-use tableware 5) A daily communication distance of >1 meter

Influence factors of isolation measures

1) Family support 2) Career reason 3) Others

Return visit

1) Yes 2) No

Satisfaction

Scores (1 to 100)

Current confusion

Next follow-up time

Date