COVID-19 Exposure Questionnaire

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? *

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 traveled during the last 14 days from anywhere there is community transmission of CoVid-19? *

Where have you traveled during the last 14 days where you may have been exposed to CoVid-19?

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