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DAILY

Name of the age


SL NO OP / IP No Patient Name Sex
Hospital
DAILY REPORTING OF ILI LINE LIST DATE: 08.09.23 INSTITUTIO

Mobile number
DAILY REPORTING OF ILI LINE LIST DATE: 08.09.23 INSTITUTION NAME: GO

Present resident address details with Village and Block and pin code
(last one month)
E: GOVT DHARMAPURI MEDICAL COLLEGE AS ON 8:00 AM

Block / Corporation Date of Onset of Date of


DISTRICT
Zone / Village symptoms Admission
AS ON 8:00 AM
Covid 19
Result Any travel Any contact
Date of Sample taken (Positive/ history History
Negative/ (Yes/No) (Yes/No)
Awaited)
Outcome
Any comorbidities like
Diabetic, HT, other (On
chronic illness Yes / No, (If Admission/
Yes Specify) Referred out/
Outpatient)
NO
NO

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