
Patient Information
*
*
*
*
*
*
*
*
*
Yes
No
*
Travel
Diagnostic
Work Requirement
Others
Current Address in the Philippines and Contact Information
*
*
*
*
*
*
*
*
*
Current Workplace Address and Contact Information
NOTE: CHECK IF ALL IS NOT APPLICABLE
*
*
*
*
*
*
*
*
Permanent Address and Contact Information
*
*
*
*
*
*
*
*
*
Address Outside the Philippines and Contact Information
(for Overseas Workers and Individuals)
NOTE: CHECK IF ALL IS NOT APPLICABLE
*
*
*
*
*
*
*
*
Consultation and Admission Information
*
Yes
No
*
*
Yes
No
*
*
Disposition at Time of Report
*
Yes
No
*
Yes
No
*
Yes
No
*
Yes
No
Health Status at Consult
Asymptomatic
Mild
Moderate
Severe
Critical
Special Population
*
Yes
No
*
Yes
No
*
Yes
No
*
Yes
No
*
Yes
No
Clinical Information
*
Asymptomatic
Fever
Cough
General weakness
Fatigue
Headache
Myalgia
Sore throat
Coryza
Dyspnea
Anorexia
Nausea
Vomiting
Diarrhea
Altered Mental Status
Anosmia (loss of smell)
Ageusia (loss of taste)
Others
*
None
Hypertension
Diabetes
Heart Disease
Lung Disease
Gastrointestinal
Genito-urinary
Neurological Disease
Cancer
Others
Yes
No
Yes
No
Yes
No
Chest Imaging findings suggestive of COVID-19
Imaging Done (Check all that apply) | Results |
---|---|
Chest radiography
|
Normal
Hazy opacities, often rounded in morphology, with peripheral
and lower lung distribution
Pending
Other findings, specify
|
Chest CT
|
Normal
Multiple bilateral ground glass opacities, often rounded in
morphology, with peripheral and lower lung distribution
Pending
Other findings, specify
|
Lung ultrasound
|
Normal
Thickened pleural lines, 8 lines (multifocal, discrete, or
confluent), consolidative patterns with or without air bronchograms
Pending
Other findings, specify
|
None
|
Laboratory Information
Yes
No
*
Exposure History
Yes
No
Unknown
Yes
No
Unknown Exposure
Place Visited | Details | Date of Visit |
---|
Travel History
Yes
No
Yes
No
Name | Contact Number |
---|
Name | Contact Number | Exposure Setting (ex. Household,Work etc.) |
---|
Select Schedule
Walk-Thru
Drive-Thru
*
*
Vaccination Information
*
Verification
Is this your name?
Is this your current address (Note: Result will only be sent to a valid email address)?
Is this your current email?
Is this your current cellphone no.?