Scribd Logo
Upload

Welcome to Scribd!

  • 19 views

    Ommc Covid 19 Checklist Final

    Uploaded by

    Eunice Rivera
    This document appears to be a screening form for COVID-19 symptoms, exposure history, comorbidities, and vital signs. It collects information such as the person's name, age, address, contact details, symptoms experienced, travel history, existing medical conditions, and measurements of respiratory rate, heart rate, blood pressure, and mental status. The form is used to assess individuals who may have been exposed to or infected with COVID-19.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Ommc Covid 19 Checklist Final

    Uploaded by

    Eunice Rivera
    19 views1 page
    This document appears to be a screening form for COVID-19 symptoms, exposure history, comorbidities, and vital signs. It collects information such as the person's name, age, address, contact details, symptoms experienced, travel history, existing medical conditions, and measurements of respiratory rate, heart rate, blood pressure, and mental status. The form is used to assess individuals who may have been exposed to or infected with COVID-19.

    Original Title

    OMMC-COVID-19-CHECKLIST-FINAL

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document appears to be a screening form for COVID-19 symptoms, exposure history, comorbidities, and vital signs. It collects information such as the person's name, age, address, contact details, symptoms experienced, travel history, existing medical conditions, and measurements of respiratory rate, heart rate, blood pressure, and mental status. The form is used to assess individuals who may have been exposed to or infected with COVID-19.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    19 views1 page

    Ommc Covid 19 Checklist Final

    Uploaded by

    Eunice Rivera
    This document appears to be a screening form for COVID-19 symptoms, exposure history, comorbidities, and vital signs. It collects information such as the person's name, age, address, contact details, symptoms experienced, travel history, existing medical conditions, and measurements of respiratory rate, heart rate, blood pressure, and mental status. The form is used to assess individuals who may have been exposed to or infected with COVID-19.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    NAME NAME

    AGE/SEX AGE/SEX
    ADDRESS ADDRESS
    CONTACT CONTACT
    NUMBER NUMBER
    YES NO SYMPTOMS YES NO SYMPTOMS
    Fever (≥ 38°C) Fever (≥ 38°C)
    Cough Cough
    Shortness of breath Shortness of breath
    Difficulty of breathing Difficulty of breathing
    Diarrhea Diarrhea
    General weakness General weakness
    Sore throat Sore throat
    Runny nose Runny nose
    Nausea / Vomiting Nausea / Vomiting
    Headache Headache
    Pain (Muscular / Abdominal / Pain (Muscular / Abdominal /
    Chest / Joint) Chest / Joint)
    YES NO EXPOSURE / TRAVEL HISTORY YES NO EXPOSURE / TRAVEL HISTORY
    Travel or residence in a country Travel or residence in a country
    / area reporting local / area reporting local
    transmission of COVID-19 transmission of COVID-19
    Close contact with a confirmed Close contact with a confirmed
    COVID-19 case or PUI COVID-19 case or PUI
    YES NO COMORBIDITIES YES NO COMORBIDITIES
    Pregnancy (Trimester:_______) Pregnancy (Trimester:_______)
    Post-partum (<6 weeks) Post-partum (<6 weeks)
    Cardiovascular disease, Cardiovascular disease,
    including Hypertension including Hypertension
    Diabetes Diabetes
    Liver disease Liver disease
    Renal disease Renal disease
    Chronic lung disease Chronic lung disease
    Chronic neurological or Chronic neurological or
    Neuromuscular disease Neuromuscular disease
    Immunodeficiency, including Immunodeficiency, including
    HIV HIV
    Malignancy Malignancy
    Others, specify: Others, specify:
    YES NO SIGNS YES NO SIGNS
    Altered mental status Altered mental status
    RR < 30 cpm RR < 30 cpm
    HR < 125 bpm HR < 125 bpm
    SBP > 90 mmHg SBP > 90 mmHg
    DBP > 60 mmHg DBP > 60 mmHg
    Assessed By: Assessed By:

    You might also like