Deceleration form related to the travel history of patient

1. Enclosure 1
Declaration Form
Related to Travel History & Health Conditions in View of Outbreak of COVID-19
Ref: Society of emergency medicine india (SEMI) Ver. 1.1
Patient Information:
Name: Age/Sex:
UHID NO.: IP / OP NO.:
Date of admission / consultation with Dr.: Admitted / Consultation Under Dr.:
Bed No: Ward:
Date of Birth: Nationality:
Mobile No. Email Id -
Next to Kin / Guardian Name: Relationship with Patient:
Contact No.: Alternative No.:
Travel History:
Name of city / country visited during last 15 days
S No. Name of City Country
Mode of
Transport
Date of Transfer
From To
1.
2.
3.
4.
5.
Health Condition
1. Do you have flu-like symptoms in last 15 days since prior from filling up this form?
Sneezing productive Cough Fever Headache Muscle Pain
Vomiting Difficulty Breathing Anorexia Sore Throat Fatigue
2. A) Were you hospitalized in last 1 month? Yes No
B) If yes please provide following details:
Name of the hospital: ___________________________________________________________
City: __________________Country: _____________________ Contact No.: _______________
Date of Admission: ____________________ Date of Discharge: ________________________
Diagnosis: ___________________________________________________________________
I, hereby declare that information provided is correct and true to my knowledge and belief. I authorize the hospital
to share this information with relevant authorities. During the lockdown and in the wake of the current Corona
companion, I come to the hospital for an emergency treatment. If I am an asymptomatic carrier or an undiagnosed
patient of COVID - 19, I believe that it may endanger doctor and hospital staff and it is my responsibility to take
appropriate precautions and to follow the protocols prescribed by them. I also know that I may get an infection from
the doctor or hospital staff, and I will take every precaution to prevent this from happening, but in any situation I
will not hold doctors and hospital staff accountable of such infections occurs to me or my accompanying persons.
Address: ____________________________________________________________________________________
____________________________________________________________________________________________
Pin Code: __________________________________ State: __________________________________________
Signature