INFORMED CONSENT QUESTIONNAIRE AND AUTOEVALUATION FOR COVID-

19 DISCHARGE

Date: ____/____/____

PATIENT’S INFORMATION

Name and last names:

Sex: □ Male □ Female

Date of birth (DD/MM/YYYY): ___/___/___

Phone number (mobile):

Age (years, months): ___ years ___ months

E-mail address:

Address:

National identification number/social

security:

Country of residence:

CONTACT RISK INFORMATION. HUMAN EXPOSURE THE DAYS PRIOR TO SHOWING

SYMPTOMS (IN THE LAST 14 DAYS)

Have you taken any domestics trips in the last □ Yes □ No

14 days?
If you have, dates of trips (DD/MM/YYYY):
from ___/___/___ to ___/___/___

Regions visited:

Provinces visited:
Have you traveled abroad in the last 14 days? □ Yes □ No

If you have, dates of trips (DD/MM/YYYY):

from ___/___/___ to ___/___/___

Countries visited:

Cities visited:

In the last 14 days, have you been in contact □ Yes □ No □ Unknown

with a person with a suspicious infection or a
If you have, dates from last contact
confirmed infected person of the COVID-19
(DD/MM/YYYY): ___/___/___
virus?

The patient assisted to a celebration or a mass □ Yes □ No

gathering in the last 14 days
If yes, specify:

The patient was exposed to a similar infection □ Yes □ No □ Unknown

in the last 14 days

Places of exposure in the last 14 days □ Home □ Hospital □ Work place □ Touristic
group trip □ University □ Other (specify):

The patient went to or was admitted to a □ Yes □ No

health center in the last 14 days
If yes, be specify:

The patient went to an ambulatory health □ Yes □ No

center in the last 14 days
If yes, specify:
Patient’s occupation (write location and □ Health worker □ Works with animals □
name) Works in a lab in the health area □ Student
□ Other (specify):

In any case, make sure to write location or

center’s name:

KNOWLEDGE OF COVID-19 DISEASE

I know what Corona Virus or COVID-19 is □ YES □ NO

I have heard about the virus or COVID-19 □ YES □ NO

I know the symptoms that COVID-19 can cause □ YES □ NO

PATIENT’S SYMPTOMS (SINCE SYMPTOMS STARTED SHOWING)

(≥38 °C) Fever or record of fever □ Yes □ No

Sore throat □ Yes □ No

Rhinorrhea (nasal congestion with nose, □ Yes □ No

mouth secretion, and teary eyes)

Cough □ Yes □ No

dyspnea (breathing difficulty) □ Yes □ No

Vomit □ Yes □ No

Nauseous □ Yes □ No

Diarrhea □ Yes □ No
Cephalalgy (intense headache) □ Yes □ No

Muscular pain □ Yes □ No

Fatigue □ Yes □ No

Date in which any of these symptoms started ___/___/___

(DD/MM/YYYY)
□ Asymptomatic □ Unknown

I certified that I have read entire document and answered these questions honestly Yes

Recovery house personnel signature Patient’s signature