Screening / Pre assessment of suspected patient of COVID - 19

1. Ref: Society of emergency medicine india (SEMI)
Screening Checklist for suspected nCoV Patients
Patient Information:
Name: Age/Sex:
UHID NO.: IP / OP NO.:
Date of admission / consultation with Dr.: Admitted / Consultation Under Dr.:
Date of Birth: Nationality:
A
Clinical Features
1 Cough within the last 10 days Yes No
2 Fever > 38 C / 100 F in last 10 days Yes No
3 Breathing difficulty Yes No
B
Travel History
1 History of any international travel Yes No
2
Visited or working at any health care
facility where hospital-associated nCoV
infections have been reported
Yes No
C
Contact History
(A Person with acute respiratory illness of any degree of severity, who within
14 days prior of onset of symptoms, had any of the following)
1
History of close physical contact with a
confirmed case of nCoV infection while
the patient was symptomatic, eg:
Yes No
• Providing direct care to nCoV
patients
• Working with health care
workers infected with nCoV
• Visiting patients or staying in the
same close environment of a
nCoV patient
• Travelling together with nCoV
patient in any kind of
conveyance
• Living in the same household as
a nCov Patient
2
History of contact with any health care
facility where hospital-associated nCoV
infections have been reported
Yes No
3
History of contact with a person who
has (any one of A + any one of B) or (any
one of C 1 or 2) positive
Yes No
**If (Any one of A + any one of B) and/or (Any one of C) is marked YES, this patient should be
suspected for nCoV.
Is patient is suspected of nCoV Yes No
Signature: _________________
Name: ____________________
Date & Time: ______________

2. Ref: Society of emergency medicine india (SEMI)