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Visual triage checklist for acute respiratory infection
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* Indicates required question
Name
*
Your answer
ID
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Your answer
Phone Number
Your answer
Temperature
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Your answer
A. Exposure Risk : Contact with a confirmed case of COVID-19 ? or MERS-CoV in the last 14 Days prior to symtom onset or History of travel abroad in the past 14 days? or An Exposure to camel or camel's products (direct or indirect *) in the last 14 days prior to symptom onset ? or working in a healthcare facility
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3 points
Yes(3)
N/A
Score
Yes(3)
N/A
Score
B. Clinical Signs and Symptoms
Fever or Recent history of fever
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4 points
Yes(4)
N/A
Score
Yes(4)
N/A
Score
Cough (new or worsening)
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4 points
Yes(4)
N/A
Score
Yes(4)
N/A
Score
Shortness of breath (new or worsening)
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4 points
Yes(4)
N/A
Score
Yes(4)
N/A
Score
Headache ,Sore throat , or rhinorrhea
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1 point
Yes(1)
N/A
Score
Yes(1)
N/A
Score
Nausea , Vomiting , and/or diarrhea
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1 point
Yes(1)
N/A
Score
Yes(1)
N/A
Score
Chronic renal failure, CAD/heart failure, immuno compromised patient
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1 point
Yes(1)
N/A
Score
Yes(1)
N/A
Score
Staff Name :
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Wadha Alshammari
Watfa
Fayha
Suaad
Rehab
Rita
Nourhan
Jean
Other
Notes :
Your answer
A score 4 ask the patient to perform hand hygiene, Wear a surgical mask, Direct the patient through the respiratory pathway, and inform the MD of assessment.
MRSE-CoV or COVID-19 testing should only be performed according to case definition
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