NAME NAME

AGE/SEX AGE/SEX
ADDRESS ADDRESS
CONTACT CONTACT
NUMBER NUMBER
YES NO SYMPTOMS YES NO SYMPTOMS
Fever (≥ 38°C) Fever (≥ 38°C)
Cough Cough
Shortness of breath Shortness of breath
Difficulty of breathing Difficulty of breathing
Diarrhea Diarrhea
General weakness General weakness
Sore throat Sore throat
Runny nose Runny nose
Nausea / Vomiting Nausea / Vomiting
Headache Headache
Pain (Muscular / Abdominal / Pain (Muscular / Abdominal /
Chest / Joint) Chest / Joint)
YES NO EXPOSURE / TRAVEL HISTORY YES NO EXPOSURE / TRAVEL HISTORY
Travel or residence in a country Travel or residence in a country
/ area reporting local / area reporting local
transmission of COVID-19 transmission of COVID-19
Close contact with a confirmed Close contact with a confirmed
COVID-19 case or PUI COVID-19 case or PUI
YES NO COMORBIDITIES YES NO COMORBIDITIES
Pregnancy (Trimester:_______) Pregnancy (Trimester:_______)
Post-partum (<6 weeks) Post-partum (<6 weeks)
Cardiovascular disease, Cardiovascular disease,
including Hypertension including Hypertension
Diabetes Diabetes
Liver disease Liver disease
Renal disease Renal disease
Chronic lung disease Chronic lung disease
Chronic neurological or Chronic neurological or
Neuromuscular disease Neuromuscular disease
Immunodeficiency, including Immunodeficiency, including
HIV HIV
Malignancy Malignancy
Others, specify: Others, specify:
YES NO SIGNS YES NO SIGNS
Altered mental status Altered mental status
RR < 30 cpm RR < 30 cpm
HR < 125 bpm HR < 125 bpm
SBP > 90 mmHg SBP > 90 mmHg
DBP > 60 mmHg DBP > 60 mmHg
Assessed By: Assessed By: