Patient Information (Covid-19)

Full Name *

Age *

Gender *

Male Female

Address *

Country *

Phone Number *

Email

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1. Cough

Dry Productive

Duration

How many days ?

2. Have Fever ?

Yes No

Duration

How many days ?

Type

Continuous Intermittent

Degree of temperature

Time of aggravation and amelioration

3. Throat pain

Yes No

Duration

Sensation or feeling

4. Dysponea

Yes No

Sensation or feeling

Time of aggravation and amelioration

5. Thirst

Thirsty Thirst less

Quantity

6. Mental/Mind symptoms

Fear of death

Yes No

Fear

Suffocation Being Alone

More details

7. General Aggravation

8. General Amelioration

2. Contact details