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Symptom Checklist for COVID-19
► Current and past symptoms - Please mark with a cross X1 Fever
2 Cough
3
Shortness of Breath / Respiratory Difficulties
4
General Muscle / Joint Pain
5
Sore Throat
6 Headache7
Nausea / Vomiting
8
Congested Nose
9
Diarrhea
13
Fatigue / Exhaustion
15
Concentration Difficulties
17
Haemoptysis (Coughing up blood, spitting blood)
18 Lymphopenia (low lympocyte count)
Total number of Symptoms
10
Phlegm
11
Jaw / Facial Pain
12 Loss of Smell
14 Loss of Taste
16 Thrombocytopenia (low platelet count)
The Symptom Checklist cannot replace medical advice for the acute symptoms mentioned above. It is just a complementary tool to support the clinical diagnosis performed by your attending pyhsician.
Surname, First Name
Date of Birth (DDMMYYYY)
Probable Date of Infection
Probable Place of Infection
Date the first symptoms appeared (see COVID-19 symptom checklist)
Date of first positive diagnosis (throat swab), if available
Date of second positive diagnosis (throat swab), if available
Date of first negative diagnosis (throat swab), if available
© by ArminLabs GmbH - CEO: Armin Schwarzbach MD PhD Contact in the UK: Academy of Nutritional Medicine (AONM), St. John's Innovation Centre, Cowley Road, Cambridge, CB4 0WS
Please feel free to contact us at [email protected] or call 03331 210 305
To be used in conjunction with clinical presentation and history.
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Written permission according to data protection:
Personal data is only processed by us within the scope of necessity. According to Art. 4 paragraph 1 of Regulation (EU) 2016/679, i.e. the basic data protection regulation, "processing" means any operation or set of operations which is performed upon personal data, whether or not by automatic means, such as collection, recording, organisation, organisation, filing, storage, adaptation or alteration, retrieval, consultation, use, disclosure by transmission, dissemination or otherwise making available, alignment or combination, restriction, erasure or destruction. Further information can be found at https://www.arminlabs.com/de/disclaimer
Rights of the data subject; right to rectification pursuant; to erase (“right to be forgotten”); right to restriction of processing; right to be informed; right to data portability; right to withdraw a given consent; right to lodge a complaint:
According to § 34 of the German Federal Data Protection Act (BDSG) you are entitled at any time to ask ArminLabs GmbH and AONM for detailed information about your saved personal data. According to § 35 BDSG you can at any time request ArminLabs GmbH and AONM to correct, erase and restrict individual personal data. Furthermore, you can at any time and without stating reasons use your right of withdrawal and amend or completely revoke the given declaration of consent with immediate effect for the future. You can send the withdrawal either by post, by e-mail or by fax to the contractual partner. You will not be charged anything other than the postage costs or the transmission costs according to the basic fees in effect at that time.
Patient‘s Agreement:
_________________________
Place, Date________________________________________________
Patient's signature (including first name and surname)
References:[1] https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Steckbrief.html[2] https://pubs.rsna.org/doi/full/10.1148/radiol.2020200490
► Exposed during the 14 days preceding the onset of symptoms X
1 Travel or residence in areas with recent local transmission of COVID-19 or local groups with confirmed patients
2 Close contact* with confirmed COVID-19 patients (positive via throat swab / PCR)
3 Close contact with people from high-risk areas or local groups with reported fever or respiratory symptoms
Exposure History for COVID-19
* Close contact is defined as health-related exposures, including direct care of patients with confirmed COVID-19, working with healthcare professionals with confirmed COVID-19, visiting or staying in the same closed environment with patients with confirmed COVID-19 or members living in the same family environment with patients with confirmed COVID-19.
© by ArminLabs GmbH - CEO: Armin Schwarzbach MD PhD Contact in the UK: Academy of Nutritional Medicine (AONM), St. John's Innovation Centre, Cowley Road, Cambridge, CB4 0WS
Please feel free to contact us at [email protected] or call 03331 210 305
