COVID SYMPTOM CHECKLIST
Click check box on left
if symptoms present
and add value/comment as appropriate.
DO NOT USE
special characters <, >, ', " marks in the comment section.
Patient Name:
Date:
Contact Risk
(click checkbox for Yes/No )
Travel in past 14 d
COVID contact
Constitutional Symptoms
Feverish
Fatigue
Myalgia / Athralgia
Chills / Rigors
Headache
Respiratory Symptoms
Sore throat
New cough
Sputum production
Hemoptysis
Shortness of breath
Nasal congestion
Nasal discharge
New sneezing
Anosmia
Agustia
Conjunctivitis
Ear ache
Gastrointestinal Symptoms
Nausea
Vomitting
Diarrhea
Abdominal Pain
Other:
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Vital Signs:
BP:
HR:
Temp:
SpO2:
Swab Done:
Swab Priority:
Swab Lot/Exp date:
Subject: