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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:
Trouble breathing
Persistent pain or pressure in the chest
New confusion
Inability to wake or stay awake
Bluish lips or face
Decrease in urine output or inability to keep fluids down because of vomiting
Severe lightheadness or fainting
Swelling in one or both legs
Have you been tested for COVID-19 in the Past?
Yes
No
Explain
Do you have a pending COVID-19 test?
Yes
No
Explain
Have you received influenza immunization this year?
Yes
No
Explain
Over the Past 2 weeks, have you been in contact with someone with known or suspicious COVID-19 infection?
Yes
No
Explain
Have you over the past month traveled overseas or to any area with high number of people infected by COVID-19?
Yes
No
Explain
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
Yes
No
Explain
Cough
Yes
No
Explain
Shortness of breath or difficulty breathing?
Yes
No
Explain
Muscle or body ache?
Yes
No
Explain
Headache
Yes
No
Explain
Fatigue?
Yes
No
Explain
New Loss of Taste or Smell?
Yes
No
Explain
Sore Throat?
Yes
No
Explain
Congestion or Runny nose?
Yes
No
Explain
Nausea or Vomiting?
Yes
No
Explain
Diarrhea?
Yes
No
Explain
Lightheadness with standing?
Yes
No
Explain
Have you tried any treatment?
Yes
No
Explain
Do you have any chronic medical conditions like Cancer, Diabetes, HTN, Heart, Lung, Kidney, Low Immune system, or Liver disease?
Yes
No
Explain
Do you have any allergies to any medications?
Yes
No
Explain
Do you take any medication on regular basis?
Yes
No
Explain
Do you smoke?
Yes
No
Explain
Oxygen Level, if known
Temperature, if known
Note