COVID-19 Risk Assessment & Care Plan


During this COVID-19 pandemic, it is important to maintain an understanding of your current health condition. To evaluate yourself, kindly take this brief and free online survey in order to get a recommendation on how to keep yourself, your family and neighbors safe. It is recommended that you take this online survey again incase your current health situation of circumstance changes.

This survey and associated recommendations do not constitute medical advice. This survey and associated recommendations are not meant to be a substitute for professional medical advice, including diagnosis or treatment. Contact your physician with any questions you may have regarding COVID-19 or your personal health. If you are experiencing a medical emergency, seek immediate assistance.


Exposure Evaluation


This section will evaluate the possibility of exposure

Have you been near someone with symptoms related to the COVID-19 infection or near someone confirmed through a laboratory test to be infected with the COVID-19 infection or near someone with pending COVID-19 laboratory test results?

 
 

Were you within 6 feet of the patient for at least 30 minutes?

 
 

Personal Risk


This section will evaluate whether you're at risk from complications from COVID-19 if you were to be infected.

Do you have any chronic medical conditions?

 
 

What chronic conditions do you have?

1. Chronic kidney disease:
2. Organ or bone marrow transplant:
3. Active hepatitis B infection:
4. Chronic liver disease:
5. Active hepatitis B infection:
6. Any cardiovascular/heart disease including high blood pressure:
7. Diabetes:
8. Any chronic lung disease or condition, including asthma, COPD/chronic emphysema or interstitial lung disease (such as pneumonitis or pulmonary fibrosis):
9. Blood disorders such as sickle cell anemia:
10. Metabolic/mitochondrial disorders:
11. Neurologic/neurodevelopmental conditions including stroke, intellectual disability, moderate to severe neurodevelopmental delay and neuromuscular diseases:
12. Any immunocompromising diseases or medications (diseases or medications that weaken your immune system):

Are you over the age of 60?

 
 

Do you, or have you ever, smoked?

 
 

If applicable, are you pregnant or have you been pregnant in the last two weeks?

 
 

Symptoms Evaluation


This section will to evaluate any of your symptoms

Do you have any of the following symptoms?

1. Fever (temperature >100.4 F or 38 C or feeling like you have a fever):
2. New or unusual cough in the past 7 days:
3. New or unusual difficulty breathing in the past 7 days (e.g., difficulty completing a sentence without gasping for air, or needing to stop to catch breath when walking across a room):
4. Feeling lightheaded, like you may pass out (faint):
5. Confusion or an inability to wake up (despite yelling / shaking):
6. None of the above:

Have you had a fever of 104 degrees or higher?

 
 

Is it responding (coming down to 102 degrees or lower) with Tylenol/acetaminophen?

 
 

Do you feel that your cough has gotten worse over the past 24 hours?

 
 

Are you coughing up more than a teaspoon of blood?

 
 

Compared to when you are not sick, how would you rate your breathlessness at rest?

                   

Are you experiencing any unusual confusion?

 
 

Have you passed out (fainted)?

 
 

Are your light-headedness symptoms worsening in the past 24 hours?

 
 

Personal Details


Kindly provide your personal details

1. Enter your first name

2. Enter your last name

3. Enter your other names

4. Enter your phone number

5. Enter your County of residence

6. Enter your Subcounty of residence

7. Enter your organization of intitution e.g Tom Mboya University College

Do you confirm that data you have entered is accurate?

 
 

Self Assessment Report

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1. Exposure Evaluation Result

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2. Personal Risk Evaluation Result

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3. Symptoms Evaluation Result

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4. Symptoms Progress Evaluation Result