NanoHealth

Covid19-Initial Assessment Form

Demographic Details

{label: "Name", srce logic: "@patient.name with age gndr if @patient.present?"} :

{label: "UHID", srce logic: "@patient.ptnt rgstrtn id if @patient.present?"} :

{label: "Phone", srce logic: "@patient.present? ? @patient.nmbr : ''"} :

{label: "Address", srce logic: "@patient.present? ? @patient.pm address : ''"} :

Full Name
Enter First name

Age
Please Select Date of Birth

Age must be greater than 0 and less than 125 Years

Months must be less than 12

Days must be less than 31

-

-

Days

Mnth

Yrs

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Covid19-Initial Assessment Form

Is CT chest done? *

Yes No

Other Disease *

Yes No

Vitals

Height *

Cms

Feet

Inches

BMI *

Weight *

Your Temperature?

SpO2(%) *

Respiratory Rate

Systolic

Pulse

SpO2 after 6 min walk test is

Current Symptoms

On what date did Covid-like symptoms first appear? *

Continuous coughing? *

Yes No

Difficulty breathing or shortness of breath? *

Yes No

Fatigue/Tiredness? *

Yes No

Joint or Muscle Pain? *

Yes No

Sensation of Vomiting/Vomiting *

Yes No

Rashes on the skin *

Yes No

Conjunctivitis *

Yes No

Discolouration of fingers and skin *

Yes No

Other Symptoms? *

Yes No

How many COVID19 vaccine doses have you taken? *

None First dose only Second dose

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Covid19-Initial Assessment Form

Clinic/Hospital/Doctor

Digital

Self

Existing Patient

Others

Corporate

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Covid19-Initial Assessment Form

Edit Referral

Clinic/Hospital/Doctor

Digital

Self

Existing Patient

Others

Corporate

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