COVID-19

Self Assessment Scan

Title
Your Name
Your Phone
Your Email (optional)
Address (Permanent) ………………………. (District)
Province (Permanent)
Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7
Current Address ………………………. (District)
Province (Current)
Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7
What is your age?
Sex:
Male Female Others Prefer not to mention
What is your body temperature (in degree Fahrenheit)?
Normal (96˚F - 98.6˚F) Fever (98.6˚F - 102˚F) High fever (>102˚F) Don’t know/Not measured
Do you have cough?
Yes No
What is the type of cough?
Dry Cough Productive Cough None of these
Do you have difficulty in breathing (shortness of breath)?
Yes No
Are you experiencing unusually high fatigue (exhaustion)?
Yes No
Do you have sore throat?
Yes No
Are you experiencing headache?
Yes No
Are you experiencing body aches and muscle pain?
Yes No
Are you experiencing chills during fever ?
Yes No
Are you experiencing nausea and vomiting?
Yes No
Do you have stuffy nose?
Yes No
Are you having abdominal upset/ diarrhoea?
Yes No
Have you travelled to COVID-19 affected area/country recently?
Yes No
When did you travel to COVID-19 affected area/country?
Last 14 days 1 month ago More than 1 month ago None of these
Where did you travel (which country)?
Did you came in contact with person having Covid-19 or having symptoms of Covid-19 in last 14 days ?
Yes No
Have any of your family members travelled to COVID-19 affected area/country recently?
Yes No
When did your family members travel to COVID-19 affected area/country recently?
Last 14 days 1 month ago More than 1 month ago None of these
Where did s/he travelled (which country)?
Do you have existing medical conditions? (select all that apply)
high blood pressure heart disease Chronic lung disease Cancer Diabetes No any conditions
What is the condition of you symptoms in last 24 hours ?
None of these Improving No any changes Getting more worse