Screening History for covid-19 or SARS- COV2

Please answer the following questions as accurately and as honestly as possible. We need to protect your
child and family and also all healthcare workers at our hospital. Your honesty would protect all of us !!

Please tick √ the appropriate reply:

1. History of Severe Acute Respiratory Infection (SARI)- Clinical Features
 Cough within last 10 days YES / NO

 Fever>/=38 Celsius within last 10 days YES / NO

 Difficulty in breathing or Any Flu symptoms YES / NO

2. Has you, your child / or any of your family members travelled recently ?

YES / NO
3. Have you or your child been in close contact ( even for a few minutes ) with a confirmed COVID
19 positive person ?
YES / NO
4. Have you or your child been in close contact ( even for a few minutes ) with a suspected Covid
19 positive person ?
YES / NO
5. Do you stay in a Coronavirus Hotspot as designated by the Government of Telangana ?

6. Has anyone visited you with fever, cough and cold in the last two weeks ? YES /NO

YES / NO

I declare that I have answered all the above questions correctly and honestly to the best of my
conscience and have not hidden any facts pertaining to Covid19 exposure.

Signed : ___________________________________ Name : ___________________________________

ID # ( Aadhar Card / Driver’s Licence / Ration Card ) : _______________________________

Phone number (s): __________________, ____________________