Date
Follow – up YesNo
Patient Name*
Father / Husband Name
Age in Years*
Gender* MaleFemaleTransgender
Mobile Number*
Mobile Number belongs to* PatientRelative
Occupation* Health Care WorkerPoliceSanitationSecurity GuardsOthersBusiness
Email*
Patient Aadhaar No.*
Nationality* NationalityIndianOther
Specify Other Nationality*
Current Patient Address*
Pin code*
State of Residence* Select StateMaharashtraAndhra PradeshArunachal PradeshAssamBiharChhattisgarhGoaGujaratHaryanaHimachal PradeshJharkhandKarnatakaKeralaMadhya PradeshManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttarakhandUttar PradeshWest BengalAndaman and Nicobar IslandsChandigarhDadra and Nagar Haveli andDaman & DiuThe Government of NCT of DelhiJammu & KashmirLadakhLakshadweepPuducherry
District of Residence* Select DistrictAHMEDNAGARAKOLAAMRAVATIAURANGABADBEEDBHANDARABULDHANACHANDRAPURDHULEGADCHIROLIGONDIAHINGOLIJALGAONJALNAKOLHAPURLATURMUMBAIMUMBAI SUBURBANNAGPURNANDEDNANDURBARNASHIKOSMANABADPALGHARPARBHANIPUNERAIGADRATNAGIRISANGLISATARASINDHUDURGSOLAPURTHANEWARDHAWASHIMYAVATMALOTHER
Specify Other District of Residence
Contact with Lab Confirmed Case YesNo
Aarogya Setu App Downloaded: YesNo
Sample Type
Type of Test
Name of Kit Used
Test-Purpose* TravellingPre-employmentSymptomsPre-operative
Symptoms Status* YesNo
Symptoms FeverCoughLoss of TasteLoss of SmellDiarrhoeaSore ThroatBreathlessnessOtherNone
Other Symptoms (If not mentioned above)
Date of Onset of Symptoms
Underlying Medical Condition* Chronic Lung DiseaseChronic Kidney DiseaseDiabetesHeart DiseaseCancerObesityHypertensionOtherNone
Other Underlying Medical Conditions (If not mentioned above)
Is Patient Hospitalized YesNo
Date of Hospitalization
Name of the Hospital
Hospital State
Hospital District
Sample Collected From* Containment ZoneNon Containment areaPoint of Entry
Passport No For Foreign Nationals
Received COVID 19 vaccine* YesNo
If yes type of vaccine* CovaxinCovishield
Date of Dose 1*
Date of Dose 2
Mode of Transport used to visit testing facility * Home VisitPublic TransportPrivate Transport
Public Transport* AmbulanceBusMetroTrainCabAuto
Private Transport* CarScootyBikeBicycle
Remarks
