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
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
Other
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
Other
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
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)
Please verify that you are human
*
Submit
Should be Empty: