COVID Questions

First Name

Last Name

Phone Number

Current Address, City, Zip Code

If you have any of the following symptoms, you’d need to go to an Emergency Room:

1. Trouble breathing

2. Persistent pain or pressure in the chest

3. New confusion

4. Inability to wake or stay awake

5. Bluish lips or face

6. Decrease in urine output or inability to keep fluids down because of vomiting

7. Severe lightheadness or fainting

8. Swelling in one or both legs

Have you been tested for COVID-19 in the Past?
YesNoExplain

Do you have a pending COVID-19 test?
YesNoExplain

Have you received influenza immunization this year?
YesNoExplain

Over the Past 2 weeks, have you been in contact with someone with known or suspicious COVID-19 infection?
YesNoExplain

Have you over the past month traveled overseas or to any area with high number of people infected by COVID-19?
YesNoExplain

Over the past 2 weeks have you experienced any of the following symtoms or do you currently have any of the listed symptoms?

Fever or Chills
YesNoExplain

Cough
YesNoExplain

Shortness of breath or difficulty breathing?
YesNoExplain

Muscle or body ache?
YesNoExplain

Headache
YesNoExplain

Fatigue?
YesNoExplain

New Loss of Taste or Smell?
YesNoExplain

Sore Throat?
YesNoExplain

Congestion or Runny nose?
YesNoExplain

Nausea or Vomiting?
YesNoExplain

Diarrhea?
YesNoExplain

Lightheadness with standing?
YesNoExplain

Have you tried any treatment?
YesNoExplain

Do you have any chronic medical conditions like Cancer, Diabetes, HTN, Heart, Lung, Kidney, Low Immune system, or Liver disease?
YesNoExplain

Do you have any allergies to any medications?
YesNoExplain

Do you take any medication on regular basis?
YesNoExplain

Do you smoke?
YesNoExplain

Oxygen Level, if known

Temperature, if known

Note