DATE * *************** Specimen Referral Form for SARS

COVID-2
SECTIONA RATIENT DETAIES EMERGENCY INDICATION:.
A.1 PERSONAL DETAILS:
NAME:.....
UHID:
Age.years.month
******'
*****"

Dept: .
|Date of Gender: Male Female
Unit: Ward/Bed: '*'******"''*'*'
"*'*"*""
****'
birth......
Mobile/Phone:. . (dd/mm/yYYY)
.

Unit Head:
Address: . *******'****'* **
.
.Se Family
irnstia 4 E-mail:..
State: ****vu PIN COde. .
Aarogya Setu App download: Yes No
.ss
A.2 TEST DETAILS:
LABS: Virology Lab (RT PCR) CBNAAT CoVID LAB
A.3 VACCINATION DETAIES (CBNAAT)| Trauma Centre, Microbiology (Antigen Test)U
Received
COVID-19 Vaccine: YES NO If YES type of vaccine:
Date of Dose 1:/... .Date Covaxin Covishield
of Dose 2:/
A.3 SPECIMEN INFORMATION FROMREFERRING
*Specimen type: Throat Swab AGENCY
*Collection Date:. .
Nasal Swa BAL ETA Nasopharyngeal swab Acute sera
.
If, RT-PCR test, name of the lab sassass Sample ID (Label):. ****''

where is sent for testing RT-PCR

Mode of transport use to visit
testing facility PUBLIC: Bus TrueNat CBNAAT
Metro Cab/Auto Ambulance
PRIVATE: Car Bike/Scooty/Bicycle Walk Not Applicable
A4.1 For Community
Sample collection from: Containment Zone
Cat 1: All
None Containment area testing on Demand Point of entry
symptomatic (ILI symptoms) cases
Cat 2: All asymptomatic
high-risk individual (any individual who falls under Section B2)
Cat 3: All symptomatic (ILI
symptoms) individual with history of international travel in the last 14 days
Cat 4: Allindividuals who wish to
get themselves tested
A4.2 For Hospital
Cat 1: All patients of Sever Acute
Respiratory Infection (SARI)
Cat 2: All symptomatic (ILI
symptoms) patients presenting in a healthcare setting
cat 3: Asymptomatic high-risk patients who are hospitalized or seeking immediate hospitalization
Cat4:Asymptomatic patients undergoing surgical/non-surgical invasive procedures (not to be tested more than once a week
During hospital stayY
Cat 5: All pregnant women in/near labour who are hospitalized for delivery
Cat 6: All symptomatic neonates presenting with acute respiratory/sepsis like illness
Cat 7: Patients presenting with atypical manifestations (stroke, encephalitis, pulmonary embolism, acute coronary
symptoms, Guillain Barre Syndrome, multi-system inflammatory syndrome in children (MIS-C), progressive
Gastrointestinal symptoms) based on the discretion of the treating physician
Cat 8: Allindividuals whowish to getthemselves tested
SECTIONB:MEDICALINFORMATION
B.1 CLINICALSYMPTOMS AND SIGNS
Symptomns: YES symptoms (tickif yes) NO If NO please go to B.2 section
Cough Diarrhoea Fever at evolution Abdominal pain Vomiting
Breathlessness Nausea Haemoptysis Body aches
Sore throat Chest pain Nasal discharge Sputum
Which oftheabovementioned was First Symptom .Date of onsetof First Symptoms.
B.2 PRE-EXISTING MEDICAL CONDITIONS
Heart disease chronic liver disease
Chronic lung disease Malignancy
Chronic renal diséase Diabetes Hypertensilon
Immunocompromised condition: YES NO Other underlying conditions:
B.3 HOSPITAUZATION DETAILS
Hospitalized: YES NO Hospltal State:..
Hospital ID/Number: . *****************'*°****'"*******''" Hospital District:. ************°*************"

Hospitalization Date: ****** ..dd/mmlyy) Haspital Name:

B.4 REFERRING DOCTORDETAILS
*Name of Doctor:.
****r****p************** Doctor Mobile No...
Doctor Email 1D: Place the test card here and senda picture
(Patient's Initials should also be put on the card)