NanoHealth

Covid19-Initial Assessment Form

Demographic Details

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

Smoking *

Never Reformed Current

Existing Disease/Co-morbidity

Hypertension? *

Yes No

Cardiovascular Diseases? *

Yes No

Asthma? *

Yes No

Immunocompromised condition/drugs/malignancy *

Yes No

Chronic Kidney Disease/CKD? *

Yes No

Are you currently pregnant?

Yes No

Vitals

Height *

Cms

Feet

Inches

BMI *

Weight *

Your Temperature?

SpO2(%) *

Respiratory Rate

Blood Pressure *

Diastolic

Diastolic Right

Systolic Right

Pulse

SpO2 after 6 min walk test is

Current Symptoms

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

Rashes on the skin *

Yes No

Conjunctivitis *

Yes No

Discolouration of fingers and skin *

Yes No

Vaccination Details

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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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