Contact Tracing Form
As part of contact tracing into a confirmed / suspected (possible contagious) case of COVID-19, we are following up with individuals who had contact with you
Basic Information
*
Type / الصله بالمدينة
--Please Choose / الرجاء الإختيار--
Staff / موظف
Inpatient / مراجع منوم
Sitter / مرافق
others / أخرى
*
Gender / النوع
--Please Choose / الرجاء الإختيار--
Male / ذكر
Female / أنثى
*
Name / الإسم
*
ID Number / رقم الهوية
MRN / رقم الملف الطبي
Age / العمر
--Please Choose--
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 Years
21 Years
22 Years
23 Years
24 Years
25 Years
26 Years
27 Years
28 Years
29 Years
30 Years
31 Years
32 Years
33 Years
34 Years
35 Years
36 Years
37 Years
38 Years
39 Years
40 Years
41 Years
42 Years
43 Years
44 Years
45 Years
46 Years
47 Years
48 Years
49 Years
50 Years
51 Years
52 Years
53 Years
54 Years
55 Years
56 Years
57 Years
58 Years
59 Years
60 Years
61 Years
62 Years
63 Years
64 Years
65 Years
66 Years
67 Years
68 Years
69 Years
70 Years
71 Years
72 Years
73 Years
74 Years
75 Years
Nationality / الجنسية
--Please Choose--
Saudi
Egyptian
Pakistani
Jordanian
Emirati
Syrian
Philippine
Indian
Sri Lankan
Australian
Sudanese
American
Tunisian
Algerian
Argentinian
Bangladeshi
Indonesian
Canadian
British
*
Mobile No / رقم الجوال
*
Vaccination Type / نوع اللقاح
--Please Choose--
Pfizer / فايزر
Astrazeneca / أسترازينيكا
Moderna / موديرنا
Mixed / مختلط
Not Applicable
*
Vaccination Status / حالة التطعيم
--Please Choose--
Nil / لا شيء
1st / جرعه أولى
2nd / جرعه ثانية
Booster / جرعه ثالثة
Contraindicated / يوجد موانع
*
Case Definition / تعريف الحالة
--Please Choose--
Positive / إيجابي
Suspected / مخالط
Initial Swab Date / تاريخ المسحه الأولي
Result Date / تاريخ النتيجه
Travel history in last 14days / سجل السفر في آخر 14 يومًا
--Please Choose--
NO
Local
International
Symptoms Information
We are also calling to check on you and discuss some Health recommendations with you.
Do you have experienced fever, cough, sore throat, shortness of breath, vomiting, diarrhea, or any other symptoms? If yes check box and ask about onset date and findings
Fever / حراره
Upper Respiratory / التنفس العلوي
Cough / كحه
Sore Throat / إلتهاب الحلق
Runny Nose / سيلان الأنف
Difficult Breathing / صعوبة بالتنفس
General / عام
Headache / صداع
fatigue / إعياء
Muscle pain / ألم عضلي
Gastrointestinal / الجهاز الهضمي
Vomiting / تقىْ
Diarrhea / إسهال
Abdominal pain / وجع بطن
Others / أخري
History Information
Do you have any known medical history? / هل لديك تاريخ مرضى
Diabetes Mellitus
On immunosuppressive medication
Obesity
Other Chronic Respiratory Disease
Hypertension
Active Cancer on chemo or radiotherapy
Renal transplant or on Dialysis
Sicke cell disease and Thallesemia
Ischaemic Heart Disease
Other condition
Known History of Contact to Covid positive patient in last 10 days
--Please Choose--
Yes
NO
Living Place (City or Outside/if City exact location) / مكان الأقامة
--Please Choose--
inside city private room
inside city shared room
outside alone
outside with family
outside with friends
- Identify Contacts: We are identifying individuals who may have been present at or have met with you 2 days prior 2 to onset of your symptoms or (if no symptoms 2 days prior to your swab date at Work, Residence, Event, Meeting, Eating etc
Identify Contacts / بيانات المخالطين
There are contacts / يوجد مخالطين