Patan Academy of Health Sciences



Date: FORMTEXT ????? Reference Number: FORMTEXT ?????Patient’s DetailPatient’s Name: FORMTEXT ?????Patient’s Age: FORMTEXT ?????Sex: FORMDROPDOWN Patient’s Temporary AddressProvince: FORMTEXT ?????District: FORMTEXT ?????Municipality: FORMTEXT ?????Ward: FORMTEXT ?????Patient’s Permanent AddressProvince: FORMTEXT ?????District: FORMTEXT ?????Municipality: FORMTEXT ?????Ward: FORMTEXT ?????Patient’s contact detailLandline: FORMTEXT ?????Mobile: FORMTEXT ?????Email: FORMTEXT ?????Name of hospital where patient is admitted FORMTEXT ?????Patient’s Hospital ID FORMTEXT ?????Travel and Contact HistoryDetails FORMDROPDOWN Travelled in last 28 days to the community which has detection of case FORMDROPDOWN Anyone from the family or close contact travelled last 28 days to the community which has detection of case FORMDROPDOWN History of close contact with COVID19 positive patient FORMDROPDOWN Health care worker taking care of COVID19 positive patient FORMDROPDOWN SymptomsFever FORMCHECKBOX Myalgia FORMCHECKBOX Rhinorrhea FORMCHECKBOX Anosmia FORMCHECKBOX Cough FORMCHECKBOX SOB FORMCHECKBOX Sore throat FORMCHECKBOX Diarrhea FORMCHECKBOX Comorbid conditions FORMTEXT ?????Clinical condition: FORMDROPDOWN Radiological/Test resultChest X ray FORMTEXT ?????CT Chest FORMTEXT ?????RDT FORMTEXT ?????Type of sample collected for RT-PCRNasopharyngeal FORMCHECKBOX Oropharyngeal (Throat) FORMCHECKBOX Endotracheal Aspirate FORMCHECKBOX Bronchialveolar FORMCHECKBOX TransportationSample in VTM FORMCHECKBOX Triple layer packaging done FORMCHECKBOX Cold chain maintained FORMCHECKBOX InformationSample must reach Patan Hospital, PCR lab by 10 amReports will be made available after 12-24 hoursThis form needs to be filled mandatory by clinician to send sample for COVID19 testSample from the patient not meeting the criteria of suspect and not in isolation facility won’t be accepted for COVID19 testingSample should be collected and transported in VTM in triple layer packaging and maintaining cold chainAs all testing are reported to government authority, above mentioned details need to be verified by authorized person of hospitalPlease send this form electronically to pcrlab@pahs.edu.npEDCD patient detail form is also required to fill up and sent to ewarsedcd@gmail.co and pcrlab@pahs.edu.npFocal person for COVID19Name: FORMTEXT ?????Position: FORMTEXT ?????Signature: FORMTEXT ?????Phone number: FORMTEXT ?????Email address: FORMTEXT ?????Attending DoctorName: FORMTEXT ?????Position: FORMTEXT ?????Signature: FORMTEXT ?????Phone number: FORMTEXT ?????Email address: FORMTEXT ????? ................
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