COVID 19 Self Assessment Questionnaire

COVID19 Appointment Request Questionnaire

Test Times: Monday -Friday: 8:15a to 3:30p and Saturdays: 9am to 2pm and Sundays 12pm to 4pm
Name *

First Name Last Name
Date of Birth *
Sex *
Phone No.-Please ensure we have your correct telephone number to be able to reach you *
Age *
Email-Please ensure we have your email address to communicate your results to you
example@example.com
Street Address *
City *
Zip code *
Reason for Testing *
Have you been vaccinated for COVID-19? *

Yes No
Which one?
First Dose

Month Day Year
Date
Second dose if applicable

Month Day Year
Date
1. Are you experiencing any of the following:
- Fevers, chills, body aches
- Difficulty breathing (e.g. struggling to breathe or speaking in single words)
- Cough, Sore throat, runny nose
- Chest pain, spitting out blood
- Confusion or word finding difficulty
YES NO
2. Are you experiencing any of the following:
- Pink eye
- Persisitent headaches
- Weakness or numbness in an extremitiy
- Difficulty with speech
- Facial droop
YES NO
3. Are you experiencing any of the following:
- Abdominal pain
- Nausea and vomitting
- Loose stoools
- Bloody urine
YES NO
4. Have you travelled to any country within the last 14 days?
YES NO
If yes, where?
5. Have you had close contact with a person with COVID-19 (probable or confirmed) while they were ill (cough, fever, sneezing, or sore throat)?
YES NO
6. Are you a health care worker?
YES NO
7. Do you have having underlying chronic condition including diabetes mellitus, hypertension, chronic heart disease, chronic kidney disease, liver disease or a malignancy (cancer), asthma, emphesema or other lung disease
YES NO
If yes, please specify
Do you smoke? If yes, how much?
What other medical problems do you have?
When is your surgery or procedure? It is recommended that you come in for your test about 4 days before your procedure. We will call you to help facilitate your appointment for the test after filling this form
What Covid Test are you interested in?

Rapid Covid-19 Antigen test ( free. results in 15 minutes) Rapid Covid-19, Influenza A and B ($160, results in 15 minutes) Rapid Strept Test-$80 with medical consultation by telemedicine if needed, results in 15min Rapid Covid-19 Test ASAP- $150 ( outside office hours) Covid 19 Molecular Test ( free, results in 30min) Covid PCR ($225, results in 30min)
Signature: I certify that I will be financially responsible for the cost of the covid 19 test.

Clear
If needed, kindly sign below authorizing us to send your results to a third party.

Clear
Thank you for submitting an appointment request form. Please wait for a call from our clinic to get scheduled.

The address for MHC is 4825 Olson Memorial Highway, Golden Valley, MN, 55422

Please wait in your car when you get to the clinic, call the clinic on 763 496 5708 and we will come to you.
Should be Empty:

COVID19 Appointment Request Questionnaire