Full Name
Age
Occupation
Income
Gender
No. of family relation living together
C+veYesNo
Temperature
Oximeter Reading
Address
House
Phone No.
Hospital prefrence: PHCGoverment HospitalsProvate clinicsany other
Difficulties in accessing clinic and hospitals: YesNo
Recent Hospital Visit
Why?
Treatment
Present Condition
Difficulties in accessing clinic and hospitals: YesNo
History of covid-19 related symptoms / Illness observation treated-Head of the Family / Members:
Health Insurance Details
pregnant Women YesNo
Lactating mother
Diabetics YesNo
Blood Pressure YesNo
Asthma YesNo
Sanitation / Toilet available? YesNo

Covid support sought:

Awareness
Testing
Refrence
Hospitalization
Date
Place