Check list for COVID-19, self-isolation

Name  
Date  
Follow until  
Date of birth  
Age    
Sex  
Contact a Contact a
Days at suspected person with Feve Sore Shortness Headach Muscle Abdominal Other,
Cough Chills Vomiting Diarrhea
home person with confirmed r throat of breath e aches Pain specify
COVID-19 COVID-19
Day-1
Day-2
Day-3

Day-4
Day-5

Day-6
Day-7

Day-8
Day-9

Day-10
Day-11 No No No No No No No No No No No No N/A
Day-12 No No No No No No No No No No No No N/A

Day-13 No No No No No No No No No No No No N/A

Day-14 No No No No No No No No No No No No N/A

Day-15 No No No No No No No No No No No No N/A

Day-16 No No No No No No No No No No No No N/A

Day-17 No No No No No No No No No No No No N/A

Day-18 No No No No No No No No No No No No N/A

Day-19 No No No No No No No No No No No No N/A

Day-20 No No No No No No No No No No No No N/A

Day-21 No No No No No No No No No No No No N/A

Day-22 No No No No No No No No No No No No N/A

Day-23 No No No No No No No No No No No No N/A

Day-24 No No No No No No No No No No No No N/A

Day-25 No No No No No No No No No No No No N/A

Day-26 No No No No No No No No No No No No N/A

Day-27 No No No No No No No No No No No No N/A

Day-28 No No No No No No No No No No No No N/A
Day-29 No No No No No No No No No No No No N/A
Day-30 No No No No No No No No No No No No N/A
Day-31 No No No No No No No No No No No No N/A

Day-32 No No No No No No No No No No No No N/A
Day-33 No No No No No No No No No No No No N/A

Day-34 No No No No No No No No No No No No N/A
Day-35 No No No No No No No No No No No No N/A