| Respiratory Triage Checklist | |||
| Date: | Time: | ||
| Name: | Hospital: | ||
| Circle the number reflecting the patient's condition (exposure and clinical picture) and calculate the final score: | |||
| Risks for Acute Respiratory Illnesses | Score | ||
| A. Exposure Risks | Any Patient {Adult or Pediatric) | ||
| A history of travel broad during the 14 days prior to symptom onset. | - | ||
| OR | - | ||
| Visiting or being resident of a high-risk area for COVID-19 in the kingdom during the 14 days prior to symptom onset*. | - | ||
| OR | - | ||
| A close physical contact with a confirmed case of COVID-19 or MERS-CoV in the past 14 days. | - | ||
| OR | 3 | ||
| An exposure to camel or camel's products (direct or indirect**) in the past 14 days. | - | ||
| OR | - | ||
| Working in a healthcare facility. | - | ||
| B. Clinical Signs and Symptoms and Medical History | Pediatric | Adult | |
| 1. Fever or recent history of fever. | 1 | 2 | |
| 2. Cough (new or worseni ng). | 1 | 2 | |
| 3. Shortness of breath (new or worsening). | 1 | 2 | |
| 4. Nausea, vomiting,and/or diarrhea. | - | 1 | |
| 5. Chronic renal failure, CAD/heart failure, immunocompromisd patient. | - | 1 | |
| Total Score | - | - | |