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COVID-19 Triage Form

This form helps medical staff quickly assess a patient's symptoms and risk factors to prioritize care based on the severity of a suspected COVID-19 case.

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Name

First Name

Last Name

Age

Gender

Male Female Other

Date of Birth

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Medical Insurance No.

Are you a frontline worker during this pandemic? (Police, Fireman, Nurse, Physician, etc.)

Yes No

Current Temperature (°C)

Is it more than 37.8°C?

Yes No

Does your temperature go down if you take medicine such as paracetamol?

Yes No

Does your temperature go down if you take medicine such as paracetamol?

Yes No

How long do you have this fever? (Hours/Days)

Are you coughing?

Yes No

Does it have sputum?

Yes No

What is the color of the sputum?

How long do you have this cough? (Hours/Days)

Are you having difficulty breathing?

Yes No

Are you having difficulty breathing while

Resting Walking Talking Lying down

How long have you been experiencing this breathing issues? (Hours/Days)

Do you feel weak and tired?

Yes No

How long have you been feeling this way? (Hours/Days)

Are you having headaches?

Yes No

When did the headaches start? (Hours/Days)

Are you having abdominal problems?

Yes No

When did the abdominal problems start? (Hours/Days)

Have you lost your sense of smell and taste?

Yes No

When did you start losing your sense of smell and taste? (Hours/Days)

Do you have a sore throat?

Yes No

When did your sore throat start? (Hours/Days)

Have you made a close contact with any COVID-19 positive/suspected cases or people in the last 14 days without wearing PPE?

Yes No

Have you traveled to a country that has COVID-19 community transmission?

Yes No

Signature

Sign here

Date Signed

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