Covengers

Doctor's Entry Form

Fill information about the patient

First name

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Last name

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City

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State

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Country

Weight (kgs)

Height (cm)

Ethnicity

Symptoms

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Symptoms Start Date

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Vaccination History

BCG Vaccination

No

Yes

Blood Pressure

Disease History

Does the patient have diabetes?

No

Yes

On going Medications

Diagnostics Report (if available)

Diagnostics report

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Chest X-ray

Chest X-ray

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Level of ICU care

Ventilator?

No

Yes

Other Patient Data

Other relevant document (if available)

Other relevant document

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Link to electronic health record (if available)

About Clincian

Name of the clinician

Position

Work Email

Medicines Prescribed:

Drug

Dosage

No. of Days

Other staff on protocol (if available)

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