Basic demographics

Gender *
Occupation *

Information on HCQ Prophylaxis

Have you taken Hydroxychloroquine for prophylaxis for COVID ? *
Have you taken Hydroxychloroquine for any other conditions in last 1 month *
Disease/Condition for which Hydroxychloroquine was prescribed *
Dose of Hydroxychloroquine taken *
Other drugs taken along with Hydroxychloroquine(please mention dose and duration) *
Date of treatment *
Were you aware about such regimen for SARS CoV-2 prophylaxis advised by ICMR. *
Reason for not taking Hydroxychloroquine prophylaxis *
SARS CoV-2 Exposure History *
Duration of exposure/possible exposure BEFORE starting prophylaxis
Duration of exposure / possible exposure AFTER starting prophylaxis
Any period of self isolation before/during/after HCQ prophylaxis
Indication for Hydroxychloroquine prophylaxis *
Dose Regimen followed *
Date of commencement of prophylaxis *

History Of Previous Illness

Do you have history of any of the following illnesses
Smoking *
Oral Tobacco *
Alcohol *

Treatment History

Treatment History

Vaccination History

Vaccination History

Adverse Effects

Did you observe any side effects after taking Hydroxychloroquine
Was any of the mentioned side effects required
COVID-19 test done *
Method
Result