Please enable JavaScript in your browser to complete this form.Hospital Name *NameFirstLastMR. No.Test ResultConfirmedSuspectAdmission DateDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Discharge DateDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Bio-dataFather NameFather's / Mother's CNICDate of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *Gender *MaleFemaleDistrict *Contact No *Social Class *UpperLowerMiddleReported Ethnicity *PunjabiSindhiBalochiPathanSaraikiKashmiriFamily StatusFather *PositiveNegativeMother *PositiveNegativeSiblings *PositiveNegativeOther Family Members *PositiveNegativeContact with International TravelerDirect *YesNoIndirect *YesNoContact with covid-19 Positive person *YesNoClustering onset *YesNoHistory *Fever High GradeFever Low GradeCoughRhinorrheaBody aches & painsVomitingDiarrheaResp. difficultyAbdominal painPoor feedingDeterioration in conscious level / FitsCo-morbid Conditions *AsthmaBronchiectasisCong. Heart DiseaseRenal DiseaseImmune DeficiencyChronic Liver DiseaseDiabetes MellitusMalnutritionOther Significant HistoryExaminationWeight *Height *HRRR/minTempBPO2 SaturationVaccination status *CompletePartialNot doneBCG ScarTreatment *No treatmentCPAPMechanical ventilationTracheostomyPlasma therapyOxygenAntibiotics: Oral / IVAugmentinAmikacinCeftriaxoneVancoTanzoSulzoneOther Treatment *SteroidsAntiviralhydroxychloroquineAzithromycinRadiologyCXR *ECG *CT Scan *LaboratoryHBTLCPlateletsALTUreaCreatininePT/APTTLDHFerritinD-DimersSerological Testing (if done) Igm / IgGOutcomeOutcome *DischargedDeathLAMASubmit 2020-10-05
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