Death Summary Form for Covid-19

(Proforma to be filled up for the Covid-19 confirmed patients who have died)

1. Name of the Hospital :

2. Patient identification :

(1) Date of Birth (dd/mm/yyyy) Age (in years)

(2) Sex Male Female

If female, was the patient pregnant ?

Yes (weeks pregnant) No Unknown

(3) Residential status Urban Rural (specify address with contact)

(4) Address:

(5) Contact No.:

(6) Referred from Hospital / Home

If Hospital, name of the previous Hospital where treatment as given

3. Clinical data

Date of onset of symptoms :

Please tick (one or more than one) symptoms the patients had

Signs and symptoms with duration

Mild Fever High grade fever Cough

Breathlessness Headache and body ache Chest pain

Running nose Fall in BP Sore throat

Sputum with blood Vomiting Diarrhoea

Any other, specify

Any associated high risk illness/ condition

Immunosuppressive condition:

Cortisone therapy Yes No Unknown

HIV + ve only Yes No Unknown

AIDS Yes No Unknown

Diabetes mellitus Yes No Unknown

Cancer Yes No Unknown

Lung diseases Yes No Unknown

Heart diseases Yes No Unknown

Kidney diseases Yes No Unknown

Liver diseases Yes No Unknown

Blood disorders Yes No Unknown

Neurological disorders Yes No Unknown

Any others, specify

4. Diagnostic findings :

Radiological tests :

COVID -19 TESTING :

Date of collection of sample :

Date of declaration of result :

Any other abnormal Laboratory test:

5. Treatment details:
 Date of reporting to this facility :

Date and time of admission :

General condition at the time of admission:

History of taking any treatment before admission :

Treatment given in the Hospital where the patient died :

Treatment for complications (details)

Mechanical ventilation required Yes No

Date and time of death :

Name and signature of Reporting Doctor / Medical Superintendent

Date :