Covid Registration

Date

Follow – up
YesNo

Patient Name*

Father / Husband Name

Age in Years*

Gender*
MaleFemaleTransgender

Mobile Number*

Mobile Number belongs to*
PatientRelative

Email*

Patient Aadhaar No.*

Nationality*

Specify Other Nationality*

Current Patient Address*

Pin code*

State of Residence*

District of Residence*

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

Other Symptoms (If not mentioned above)

Date of Onset of Symptoms

Other Underlying Medical Conditions (If not mentioned above)

Is Patient Hospitalized
YesNo

Sample Collected From*
Containment ZoneNon Containment areaPoint of Entry

Passport No For Foreign Nationals

Received COVID 19 vaccine*
YesNo

Remarks

Clinical Data