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ICMR Specimen Referral Form for COVID-19 (SARS-CoV2)
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* Indicates required question
Email
*
Your email
Please select your required Test
*
Rapid Antigen detection Test
RTPCR
Truenat /CBNATT
Antibody Test
Required
SECTION A – MANDATORY FIELDS (FORM WILL NOT BE ACCEPTED IN CASE OF ANY BLANK)
A.1 Person details
Patient Name
*
Your answer
Age
*
Your answer
Gender
*
Male
Female
Others
Present Village or Town
*
Your answer
District of present residence
*
Your answer
Nationality
*
Your answer
State of present residence
*
Your answer
Mobile number
*
Your answer
Mobile number belongs to
*
Self
Family
Other
A.3 PATIENT CATEGORY (PLEASE SELECT ONLY ONE)
*
Cat 1: Symptomatic international traveller in last 14 days
Cat 2: Symptomatic contact of lab confirmed case
Cat 3: Symptomatic healthcare worker
Cat 4: Hospitalized SARI (Severe Acute Respiratory Illness) patient
Cat 5a: Asymptomatic direct and high risk contact of confirmed case – family member
Cat 5b: Asymptomatic healthcare worker in contact with confirmed case without adequate protection
B.1 PERSON DETAILS
Present patient address
Your answer
Pin code
Your answer
Date of Birth
MM
/
DD
/
YYYY
Email id
Your answer
Patient Passport Number
Your answer
Patient Aadhar No
Your answer
B.2 EXPOSURE HISTORY(2 WEEKS BEFORE THE ONSET OF SYMPTOMS)
B.2.1. Did you travel to foreign country in last 14 days:
Yes
No
Clear selection
If yes , place(s) of travel
Your answer
Stay/travel duration: Fr Date and To date
Your answer
Option 1
Clear selection
B.2.2. Have you been in contact with lab confirmed COVID-19 patient:
Yes
No
Clear selection
If Yes Name of the confirmed patient
Your answer
B.2.3. Were you Quarantined?:
Yes
No
Clear selection
If yes, where were you quarantined
Home
Facility
Clear selection
3.2.4. Are you a health care worker working in hospital involved in managing patients
Yes
No
Clear selection
B.3 CLINICAL SYMPTOMS AND SIGNS
Date of onset of symptoms
MM
/
DD
/
YYYY
First symptom
Your answer
Symptoms
Cough
Breathlessness
Sore throat
Option 4
Sputum
Diarrhoea
Nausea
Chest pain
Abdominal pain
Vomiting
Haemoptysis
Nasal discharge
Fever at evaluation
Body ache
Clear selection
Any symptoms If yes; From Date ,To date and History
Your answer
Respiratory infection at sample collection:Severe Acute Respiratory Illness (SARI)
Yes
No
Clear selection
ARI
Yes
No
Clear selection
B.4 UNDERLYING MEDICAL CONDITIONS
Please select
COPD
Chronic renal disease
Bronchitis
Malignancy
Diabetes
Heart disease
Asthma
Clear selection
IMMUNOCOMPROMISED CONDITION: Yes/No
Your answer
Other underlying conditions:
Your answer
B.5 HOSPITALIZATION, TREATMENT AND INVESTIGATION
Hospitalization date AND Out come date
Your answer
DIAGNOSIS
Your answer
DIFFERENTIAL DIAGNOSIS
Your answer
ETIOLOGY IDENTIFIED
Your answer
ATYPICAL PRESENTATION
Yes
No
Clear selection
ETIOLOGY IDENTIFIED
Your answer
UNUSUAL / UNEXPECTED COURSE
Yes
No
Clear selection
OUTCOME: Discharge/Death/
Your answer
Hospital Name/address
Your answer
Name of Doctor
Your answer
DETAILS OF HEALTH AUTHORITY (FOR SENDING THE REPORT)
Name of Doctor
Your answer
Hospital Name /address
Your answer
EMAIL ID
Your answer
Phone /mobile number
Your answer
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