VSMMC Online Swabbing Registration
Patient Information
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Travel
Diagnostic
Work Requirement
Others
Current Address in the Philippines and Contact Information
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Current Workplace Address and Contact Information
NOTE: JUST PUT N/A IF NOT APPLICABLE
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Permanent Address and Contact Information
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Address Outside the Philippines and Contact Information (for Overseas Workers and Individuals)
NOTE: JUST PUT N/A IF NOT APPLICABLE
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Consultation and Admission Information
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Yes
No
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No
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Disposition at Time of Report
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No
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No
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No
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Health Status at Consult
Asymptomatic
Mild
Moderate
Severe
Critical
Special Population
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No
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No
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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
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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
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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.)
Setting up Schedule
Walk-Thru
Drive-Thru
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Vaccination Information
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Verification
Is this your name?
Is this your current address?
Is this your current email?
Is this your current cellphone no.?