MEDIHEAL HOSPITAL, 3RD PARKLANDS, NAIROBI

Lab Requisition Form for 2019 Novel Coronavirus (Covid-19)

(Kindly Fill the TRF in Capital Letters Only)

1. Alphanumeric Code :
2. Date :
3. Reason for Testing : (1) Surveillance (2) Air Travel (3) Truck Driver (4) Others
4. Type of Case : (1) Initial (2) Repeat
5. Case ID :
6. Sample Number :
Section 1: Patient Information

a. Full Name :
b. National ID/Passport No :
c. Age :
d. DOB (DDMMYY) :
e. Gender: :
f. Mobile No :
g. E Mail Address :
h. Occupation :
i. Nationality :
j. County of Residence :
k. Sub county :
l. Village/Ward :
m. County of Diagnosis :
n. Next of Kin Name/Contact No :
o. Marital Status : (1) Married (2) Unmarried (3) Divorcee (4) Others
p. Place of the case Investigated : (1) Household (2) Mass Testing (3) Quarantine (4) Health Facility
q. Vaccination Status : (1) Yes (2) No
r. Vaccination Doses : (1) Complete (2) Not Complete

Section 2: Clinical Information :

Patient Clinical Course:

a. Date of onset of symptoms :

b. Type of Symptoms : (1) Symptomatic (2) Asymptomatic
c. Admission to the hospital : (1) Yes (2) No
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 MEDIHEAL HOSPITAL, 3RD PARKLANDS, NAIROBI
Lab Requisition Form for 2019 Novel Coronavirus (Covid-19)
(Kindly Fill the TRF in Capital Letters Only)

 Date of Admission :
 Name of Hospital :
 Patient taken to Isolation :
 Was the patient ventilated :
 Health Status at the time of reporting :
 Patient temperature :

Patient Symptoms:
(1) History of fever/Chills (2) Shortness of breath (3) Pain (4) General Weakness
(5) Diarrhoea (6) Chest Cough (7) Nausea (8) Sore Throat
(9) Headache (10) Runny Nose (11) Irritability (12) Others
d. Underlying Condition and comorbidity:

(1) Pregnancy (2) Cardiovascular Disease (3) Diabetes (4) Liver Disease
(5) Neurological Disease (6) Smoking (7) Post-Partum Immunodeficiency
(8) Renal Disease (9) Others
Section 3: Exposure and Travel Information :
 Has the patient travelled in last 14 days? :(1) Yes (2) No
 Patient travel from :
 Has the patient had close contact with a confirmed case? : (1) Yes (2) No
 If yes, Name of the confirmed case :
Section 4: Laboratory Information :

 Was the specimen collected : (1) Yes (2) No

 Date of specimen collection :
 Specimen (Swab) type : (1) Nasopharyngeal (2) Oropharyngeal
 Date on which specimen received in the lab :
 Please specify which assay was used :
 Date of Investigation :
 Date of Laboratory Confirmation :
 Result :

Date Name & Signature of the Patient/Attendant