SECTION A – PATIENT DETAILS
A.1 TEST INITIATION DETAILS
(Prescription is not mandatory , kindly attach if available)
A.2 PERSONAL DETAILS
(These fields to be filled for all patients including foreigners)
A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY (Not to be filled by Patient)
A.4 PATIENT CATEGORY (PLEASE SELECT ONLY ONE)
A.4.1 Routine surveillance in containment zones and screening at points of entry :
A.4.2 Routine surveillance in non-containment areas :
A.4.3 In Hospital Settings :
A.4.4 Testing on demand :
SECTION B- MEDICAL INFORMATION
B.1 CLINICAL SYMPTOMS AND SIGNS
If No please go to B.2 section
B.2 PRE-EXISTING MEDICAL CONDITIONS
B.3 HOSPITALIZATION DETAILS
B.4 REFERRING DOCTOR DETAILS