Order Number Select Location Howrah Liluah Kolkata Date Time Patient Name DOB Gender Male Female Mobile Number Email Present Address Municipal Ward Village Town District State Pincode Nationality Adhar Number Passport No.(Foreign) Have you installed Arogya Setu app? Yes No Did you travel to foreign country in last 14 days Yes No If yes place of travel Duration of travel from Duration of travel to Have you been in contact with lab confirmed COVID-19 patient (required) Yes No If yes name of confirmed patient Were you Quarantined? Yes No If yes where you quarantined ? Home Facility Centre Are you a health care worker working in hospital involved in managing patients Yes No Date of onset of symptoms First Symptom Sever Acute Respiratory illness [SARI] Yes No ARI Yes No UNDERLYING MEDICAL CONDITIONS COPD Chronic renal disease Bronchitis Malignancy Diabetes Heart disease Hypertension Asthma IMMUNOCOMPROMISED CONDITION Attachments
