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2021-04-20T13:58:40+05:30
Date
Follow – up
Yes
No
Patient Name*
Father / Husband Name
Age in Years*
Gender*
Male
Female
Transgender
Mobile Number*
Mobile Number belongs to*
Patient
Relative
Occupation*
Health Care Worker
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Email*
Patient Aadhaar No.*
Nationality*
Nationality
Indian
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Specify Other Nationality*
Current Patient Address*
Pin code*
State of Residence*
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Maharashtra
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District of Residence*
Select District
AHMEDNAGAR
AKOLA
AMRAVATI
AURANGABAD
BEED
BHANDARA
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CHANDRAPUR
DHULE
GADCHIROLI
GONDIA
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SATARA
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SOLAPUR
THANE
WARDHA
WASHIM
YAVATMAL
OTHER
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Contact with Lab Confirmed Case
Yes
No
Aarogya Setu App Downloaded:
Yes
No
Clinical Data
Sample Type
Type of Test
Name of Kit Used
Test-Purpose*
Travelling
Pre-employment
Symptoms
Pre-operative
Symptoms Status*
Yes
No
Symptoms
Fever
Cough
Loss of Taste
Loss of Smell
Diarrhoea
Sore Throat
Breathlessness
Other
None
Other Symptoms (If not mentioned above)
Date of Onset of Symptoms
Underlying Medical Condition*
Chronic Lung Disease
Chronic Kidney Disease
Diabetes
Heart Disease
Cancer
Obesity
Hypertension
Other
None
Other Underlying Medical Conditions (If not mentioned above)
Is Patient Hospitalized
Yes
No
Date of Hospitalization
Name of the Hospital
Hospital State
Hospital District
Sample Collected From*
Containment Zone
Non Containment area
Point of Entry
Passport No For Foreign Nationals
Received COVID 19 vaccine*
Yes
No
If yes type of vaccine*
Covaxin
Covishield
Date of Dose 1*
Date of Dose 2
Mode of Transport used to visit testing facility *
Home Visit
Public Transport
Private Transport
Public Transport*
Ambulance
Bus
Metro
Train
Cab
Auto
Private Transport*
Car
Scooty
Bike
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