Patient Assessment Form (PCDDE DEMO)

Age Range: 0-2 3-20 21-40 41-60 60+ Temperature (°C): Comorbidities: None Diabetes Hypertension Cardiovascular Disease Respiratory Disease Symptoms: Cough Fever Headache Fatigue O2 Saturation (%): COVID vaccine doses: 0 1 2 3 more than 3 Last COVID vaccine dose: not vaccinated 24+ months ago 12 - 24 months ago 6 - 12 months ago 3 - 6 months ago 0 - 3 months ago