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diagnostics@medgenome.com
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COVID-19 (SARS-CoV2) RT-PCR test

INTRODUCTION

This form is for collection centres/ labs to enter details of the samples being tested for Covid-19. It is mandatory to fill this form for each and every sample being tested.

INSTRUCTIONS

  • Inform the local / district / state health authorities, especially surveillance officer for further guidance
  • Seek guidance on requirements for the clinical specimen collection and transport from nodal officer
  • This form may be filled in and shared with the IDSP and forwarded to a lab where testing is planned
  • Fields marked with asterisk (*) are mandatory to be filled

section a - patient details
a.1 test initiation details
Yes No
(File size should not be exceed 2MB
.jpg, .pdf - format files only allowed)
Yes No
a.2 personal details
Yes No
(These fields to be filled for all patients including foreigners)
Male Female Others
Self Family
(File size should not be exceed 2MB
.jpg, .pdf - format files only allowed)
a.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
Throat Swab
Nasal Swab
BAL
NETA
Nasopharyngeal Swab
a.4 PATIENT CATEGORY (PLEASE SELECT ONLY ONE)
Symptomatic international traveller in last 14 days
Symptomatic contact of lab confirmed case
Symptomatic Healthcare worker / Frontline workers
Hospitalized SARI (Severe Acute Respiratory Illness) patient
Asymptomatic direct and high risk contact of lab confirmed case - family member
Asymptomatic healthcare worker in contact with confirmed case without adequate protection
Symptomatic Influenza like Illness (ILI) in Hospital
Pregnant woman in / near labour
Symptomatic (ILI) amongh returnees and migrants (within 7 days of illness)
Symptomatic Influenza Like Illness(ILI) patient in Hotspot / Containment zones
Individuals undertaking travel to countries/Indian states mandating a negative COVID-19 test at point of entry
Individuals who wish to get themselves tested
section b - medical information
B.1 CLINICAL SYMPTOMS AND SIGNS
Yes No
(If No please go to B.2 section)
SymptomsYesSymptomsYesSymptomsYesSymptomsYes
CoughAbdominal painBody acheSputum
DiarrhoeaBreathlessnessSore throat
VomitingNauseaChest pain
Fever at evaluationHaemoptysisNasal discharge
Which of the above mentioned was First Symptom
Date of onset of First Symptom
B.2 PRE-EXISTING MEDICAL CONDITIONS
SymptomsYesSymptomsYesSymptomsYesSymptomsYes
Chronic lung diseaseMalignancyHeart diseaseChronic liver diseas
Chronic renal diseaseDiabetesHypertension
Yes No
Other underlying conditions
B.3 HOSPITALIZATION DETAILS
Yes No
B.4 REFERRING DOCTOR DETAILS
B.5 PATIENT / GUARDIAN DETAILS
I have provided true and reliable personal information for COVID-19 testing
I agree
For more information
1800 103 3691
diagnostics@medgenome.com
www.medgenome.com