Patient’s name

Gender

Male　

Age

· ID number

Female　

Screening programs

Temperature

（If hospitalization is required, the nurse measures again）

°C

The nurse signature

Clinical feature

Fever? (If the fever is ≥ 37.3°C, the following screening should be conducted by the fever clinic)

YES □

NO □

Does CT show the imaging features of pneumonia?

YES □

NO □

The total number of white blood cells was normal or decreased, or the lymphocyte count was decreased?

YES □

NO □

Epidemiological history

Travel history or residence history in the Wuhan area or other areas with continuous transmission of local cases within 14 days before onset?

YES □

NO □

Have you been exposed to fever or respiratory symptoms from Wuhan or other areas where local cases continue to circulate within 14 days before onset?

YES □

NO □

A cluster of disease? (many people around the same fever and other symptoms)

YES □

NO □

Epidemiological association with confirmed cases? (surrounding or in close contact with confirmed cases)

YES □

NO □

Patient commitment

The epidemiological history is real. If not, I will bear all the responsibility for the consequences

Patient or family member Signature：

Time：

Month Day, 2020

Conclusion

The patient with this fever does not have the diagnostic conditions for the suspected case of pneumonia caused by SARS-CoV-2 infection

The patient is admitted to hospital

Fever outpatient physician signature:

(signature and seal)

Physician signature:

(signature and seal)

Time：

Month Day, 2020

Time：

Month Day, 2020