TEST REQUISITION FORM FOR SARS-CoV-2 ANTIGEN TEST
SECTION A - PATIENTS DETAILS
A.1 PERSONAL DETAILS
Name
*
First Name
Last Name
Email
*
example@example.com
Patient in quarantine facility:
*
Yes
No
Present Village or Town:
*
District of Present Residence:
*
State of Present Residence:
*
Present Patient address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Age:
*
Gender:
*
Male
Female
Other
Nationality:
*
Mobile Number:
*
-
Area Code
Phone Number
Mobile Number belongs to:
*
Self
Family
Downloaded Aarogya Setu App:
*
Yes
No
Aadhar No (For Indians):
Passport No (For Foreign Nationals):
A.2 SPECIMEN INFORMATION
Specimen Type:
*
Nasopharyngel Swab
Collection date:
*
Sample ID (Label):
A.4 PATIENT CATEGORY (PLEASE SELECT ONE)
Cat 1: Symptomatic international traveller in last 14 days
Cat 2: Symptomatic contact of lab confirmed case
Cat 3: Symptomatic Healthcare worker / Frontline workers
Cat 4: Hospitalized SARI (Severe Acute Respiratory Illness) patient
Cat 5a: Asymptomatic direct and high risk contact of lab confirmed case - family member
Cat 5b: Asymptomatic healthcare worker in contact with confirmed case without adequate protection
Cat 6: Symptomatic Influenza like Illness (ILI) in Hospital
Cat 7: Pregnant woman in / near labour
Cat 8: Symptomatic (ILI) among returnees and migrants (within 7 days of illness)
Cat 9: Symptomatic Influenza Like Illness(ILI) patient in Hotspot / Containment zones
Other: (please specify) * (Select “other" only if the patient doesn’t belong to category 1-8)
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SECTION B- MEDICAL INFORMATION
B.1 CLINICAL SYMPTOMS AND SIGNS
Symptoms
Yes
No
If No, please go to section B.2
Symptoms
Cough
Diarrhoea
Vomiting
Fever at Evaluation
Abdominal pain
Breathlessness
Nausea
Haemoptysis
Body ache
Sore throat
Chest Pain
Nasal discharge
Sputum
Which of the above mentioned was First Symptom:
Date of onset of First Symptom:
-
Month
-
Day
Year
Date
B.2 PRE-EXISTING MEDICAL CONDITIONS
Chronic lung disease
Chronic renal disease
Malignancy
Diabetes
Heart disease
Hypertension
Chronic liver disease
Immunocompromised condition:
Yes
No
B.3 HOSPITALIZATION DETAILS
Hospitalized
Yes
No
Hospital ID / Number:
Hospitalization Date:
-
Month
-
Day
Year
Date
Hospital State:
Hospital District:
Hospital Name:
B.4 REFERRING DOCTOR DETAILS
Name of Doctor:
First Name
Last Name
Doctor Email ID:
example@example.com
Doctor Mobile No:
-
Area Code
Phone Number
Note: As per ICMR guideline if I am Symptomatic and found Negative, I have to do confirmaiton with RT-PCR test. I will follow the protocol of ICMR.
Signature of the Patient
Clear
TEST RESULT (To be filled by Covid-19 testing lab facility)
Date of sample receipt:
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Sample
Yes
No
Date of Testing
Test result
Positive
Negative
Repeat Sample Required
Yes
No
Sign of Authority (Lab in charge)
Clear
Please verify that you are human
*
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