Previsit Screening Form

All Fields Required ( Read Properly )

# Purpose of Visit to our clinic

ConsultationWant to start TreatmentUndergoing treatmentOther

Kindly Answer to all questions properly

:-

# Have You Got COVID-19 test done ?

Yes,It Was PositiveYes,It Was NegativeNo test till now

# Have you received covid-19

vaccine

NoYes, only 1 doseYes, Both doses

Select [✔] if you have/had any sign &

symptoms mentioned below:-

Select Multiple if required.

DRY COUGH in last 14 days?FEVER in last 14 days?Do you have FEVER NOW ?SORE THROAT in last 14 days?SHORTNESS OF BREATH in last 14 days?Any other FLU-like symptoms, such as gastrointestinal upset/Diarrhoea, headache or fatigue in last 14 days?LOSS OF SENSE OF TASTE or SMELL in last 14 days?RUNNY NOSE in last 14 days?I declare i am free of above mentioned signs and symptoms

# Any International travel in last 45 days ?

YesNo

# Have you traveled from outside Delhi in

last 14 days,Select [✔] which ever applicable

No Travel in 14 days from outside Delhi.Yes,By BusYes,By TrainYes, By Private VehicleYes,By Cab/TaxiYes,By Commercial Airlines/flight

# Does Any one at your Home/flatmate/

Roommate diagnosed CORONA POSITIVE

in last 14 days?

YesNo

# Were you diagnosed CORONA POSITIVE

till date?

YesNo

# Do you have Any Medical Problem or

Any Medical History:-

YesNo

Attendant / Visitor Information

(Only 1 Allowed)

Declaration [✔]

I do hereby declare that all the information given above is Correct.and I understand above information can be shared with Government bodies if required.I take full responsibility of my attendant and declare that he/she is also free of above mentioned signs and symptoms and has not traveled within India (or from outside India) using commercial Bus,Airline,Train etc in last 14 days

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