Language
English (US)
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Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
Day/Month/Year
Health Care Plan
Anthem, SCMG, Blue Shield, None, etc.
Primary Care Physician (optional)
In case we need to coordinate care
Primary Care Phone Number (optional)
In case we need to coordinate care
Are you filling this form out because you are concerned that you have been exposed to or have contracted the COVID-19 virus?
*
Yes
No
Are you experiencing any of the following symptoms?
*
Fever over 100 F
Coughing
Nasal Congestion or discharge
Body aches and pains
Difficulty breathing or shortness of breath
None of these
Do you have any of the following pre-existing medical problems?
*
Diabetes, type 1 or 2
High Blood Pressure
Cardiovascular Disease (Heart Attack/Stents/Heart Failure)
Lung Disease like COPD, Asthma or Emphysema
Autoimmune Disease like Lupus or Rheumatoid Arthritis
Medications that affect the immune system
I have none of these
Have you had direct exposure to a CoVid-19 patient?
*
Live with a know CoVid-19 patient?
Cared for a know CoVid-19 patient?
Been in the same room as a known CoVid-19 patient
Been around someone exposed to a CoVid-19 patient
Have you had any other exposures or interactions with anyone who has a laboratory confirmed case of CoVid-19?
*
Walking by Someone
Briefly in the Same Room or Indoor Confined Space
Not that I know of
Is there anything else you'd like to share with us to help determine your risk for CoVid-19?
Employer and Location
If this is an employer directed visit
Submit
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