COVID-19 PRELIMINARY

ASSESSMENT CHECKLIST
I. DATA INFORMATION
Patient’s Name: Birth Date: Sex:
Patient ID No. :
Address: Contact Number:
Company : E-mail Add :

II. CLASSIFICATION OF PATIENT

Severe Acute Respiratory Illness (SARI) NO other Influenza like Illness

YES NO YES NO
etiology fully explains the clinical presentation With any ONE of the following
Adult (> 5 years old)
 history of fever or measured fever of ≥ 38 C°;
 With no other etiology that fully
 and cough; explains the clinical presentation AND
 with onset within the last 10 days; a history of travel to or residence in an
 and requires hospitalization area that reported local transmission of
 WITH difficulty of breathing OR COVID-19 disease or during the 14
 severe undiagnosed pneumonia, Acute days prior to symptom onset OR
Respiratory Distress Syndrome, Severe  With contact to a confirmed or
Respiratory Disease probable case of COVID-19 disease
Pedia < 5 years old during the 14 days prior to onset of
Any child 2 months to 5 years of age with cough or symptoms
difficult breathing, AND
Influenza like Illness
Breathing faster than 60 breaths/min (infants < 2 With any ONE of the following
months) Individuals with fever or cough or shortness
Breathing faster than 50 breaths/min (2-12 months) of breath or other respiratory signs or
Breathing faster than 40 breaths/min (1-5 years old) symptoms fulfilling any one of the following
OR conditions:
Any child 2 months to 5 years of age with cough or  Aged 60 years and above
difficult breathing and any of  With a comorbidity
the following danger signs:  Assessed as having a high-risk
 Unable to drink or breastfeed pregnancy
 Vomits everything  Health worker
 Convulsions
 Lethargic or unconscious
III. If COVID-19 Suspect, classify if mild or severe IV. ASSESSMENT OF PATIENT
MILD SEVERE
 Non-COVID Case
Vital Signs Stable Unstable  Possible case/PUM (With exposure and contact
Respiratory Rate <30/min ≥30/min but no symptoms)
Pulse rate <125/min ≥125/min  Suspect COVID , mild
Systolic blood pressure >90 mmHg <90 mmHg  Suspect COVID , severe
Diastolic blood pressure >60 mmHg ≥60 mmHg  Probable COVID Case,mild
Temperature >36 °C or < 40 °C ≤36° C or ≥40° C  Probable COVID Case,severe
Others :Altered Mental State of  Confirmed COVID Case, mild
Absent Present
acute onset  Confirmed COVID Case,severe
None or stable co- Unstable/uncon-
Co-morbid condition
morbidities trolled
Admitting Diagnosis :
SpO2 /oxygen saturation ≤ 93%

Declaration:
I certify to the truth and correctness of the above-declared health information to the best of my knowledge, particularly
declaration of history of travel outside and contact with any person with flu-like symptoms and/or with such history of travel. I
understand that any false or non-declaration may result to corresponding consequences in the objective of protecting the health and
safety of the healthcare providers, the frontliners, the immediate community and the society in general, in accordance with RA 11332
or “Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act”

Signature Over Printed Name and Date