1. Name of the patient:
2. Father’s/Husband/Guardian’s name:
3. Contact Address:
House Number:	Road Number:		Contact Number:
4. Family members (Total):
5. Age and Sex:
a) Child (3 months to 14 years)	i) Male	ii) Female
b) Adult (More than 14 years)	i) Male	ii) Female
6. Religion:
	a) Hindu	b) Muslim	c) Christian	d) Other
7. Marital Status:	a) Married	b) Unmarried
8. Occupation:	a) Managerial	b) Skilled	c) Unskilled	d) Homemaker
	e) Other
9. Educational qualification:
	a) Ignore	b) Literate	c) Ten class	d) Twelve class
	e) Graduate	f) PG
10. Income (Monthly):
11. Immunity status:	a) Vaccinated	b) Nonvaccinated
12. Addiction (if any):	a) Alcohol	b) Drugs	c) Tobacco, tobacco product use
13. History of fever:	a) 0–9 days	b) 10–21 days	c) More than 21 days