COVID-19 Test Laboratory Request Korm nt/Patient Information Fatt Name: Sed V4 rset Sex Cliem current residency: Region j\ wa hab Rebelo specientes @.C—Nom —— SelGPhone 412. P4}0} 31 Relative Phone: O4 (336380) passport No__= - on: PGovemment employee OPrivate Employee G Driver GQ Merchant © Daily Laborer @ Swdent & Prisoner CS Howewife CG Farmer © Teacher Others, Specity Is he/she is heath eare worker professional? OY Ne Profession ofthe alt care worker Doctor Cifealth officer ONUrse/Midwie Claboratory vironmental Health Pharmacy BOthers, Specity Location of specimen collection (B Health Fasiiy, WAS es AQuarantine/sotation center __5Community © Treatment center —— © Geriatric’ orphannge center Pon of entry GDP. OPrison_ ™ ‘Gomes Barcode Number: % F_ Nationality. _C +n ae pecity Zone AF exces Word Ua Vother Information Does the patentcient have ay sytuptom compatible with COVID-I9? GYes «iB No yes, which symptom of COVID do you have? (Lick all that apply? OCoush sD Fever Shortness of breath Sore oat LossoftestC Loss of smell Headache BLasy fatigue Doin pain D Other, Specify Does the patient hae any underiying condition? ors YANo, yes, which underiyin jan do you have? (Tick all has apply) [Diabetes Mellims Hypertension QHIV GChronic respiratory disease ORenal disease © Chronic cardiac disease OTB © Pregnant Other. Speetty, Has the patienveliont had contact with a confirmed case with in the past wo wesks? Gs @ No yes, from where the client has contact history? CHouse-Hold OWerk-place OQ oll a Have you ever been participated or involved in any of mass gathering with in the past two weeks? WAYes @ No yes, in which of mass gathering was participated? (Tiek all that apply) © Mass sport, = Religious events. © fumeral event A Training or workshop © Baar O Wedding event (other, Speci Have you vaccinated for COVID 19? Yes. No If yes, which type of vaccine you scocived? Johnson and Johnson: First dose Astrazencea: CO Fitstdose © Second dose Sinophiari O First dose © Second dose Sputnik: O Firstdose © Second dose Have you ever infected by COVID 19 © Yess No yes, at what ime you infected previously? <3 mouth C3-6menth © 7-12month © >12 month - speci Reason for Testing ce | © Contaet of contin © Community surve | Cent cast >. | 1S army te tealnent center and HNC BNew 1D Repeat | go Travel purpose | Specimen Information | Sample Type}.on Spuinnn, Blood, Urine oers__ALP_cottetion Dat: sithnnr20Q4 Specimen Colleetion Time: Receiving date atthe testing lab. cil Sample Coltectea by: Phone: 0912211146 Sien |_Form completed by: Phone OV {221 £ Lab sigs’ | 1 | | Test requested Boies oue-12fiafugines S125 | Powered by (9 CamScanner | TestMetnod: RFPCR | omy Rony Mes Soni we ei seid 9