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%DON BOSCO Hogprrz,
: » N PARAVUR
eae Dai | SHEET FOR Covip-19 ANTIGEN TESTING
NAME OF PATIENT
AGE/SEX
ADDRESS
PIN CODE
PHONE NUMBER
PANCHAYATH/MUNICIPALITY WARD
DISTRICT STATE NATIONALITY
VOTERS ID/AADHAR CARD NO/PASSPORT NO
DATE OF ARRIVAL IN INDIA
PATIENT IS UNDER QUARANTINE, YES/NO if yes, no. of days
PATIENT STATUS
SYMTOMATIC / ASYMTOMATIC
IF SYMTOMATIC, (mark the symtoms that you feel)
ABDOMINAL PAIN
ANOSMIA
BODY ACHE
BREATHLESSNESSS
CHEST PAIN
COUGH
DIARRHOEA
FATIGUE
FEVER
HAEMOPTSIS
LOSS OF SMELL
LOSS OF TASTE
NASAL DISCHARGE
NAUSEA
SORE THROAT
SPUTUM
VOMITING
REASON FOR TESTING
TEST RESULT
DATE OF sayy
P
RECEIPT ue
‘REJECTED
SAMPLE ACEPTED
‘PEST RESULT
DATE OF TESTING TES