1) The document provides a screening checklist for patients suspected of having novel coronavirus (nCoV). It collects information on clinical features, travel history, and contact history to determine if the patient should be suspected of having nCoV. 2) The checklist collects data on cough, fever, breathing difficulty, international travel history, contact with healthcare facilities reporting nCoV, and close contact with confirmed nCoV cases. 3) If a patient reports a combination of clinical features and travel/contact history, including contact with a probable nCoV case, the checklist indicates they should be suspected of having nCoV and requires the assessing doctor's signature.

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)