COVID 19 Self Assessment Questionnaire

COVID19 Appointment Request Questionnaire

Test Times: Monday -Friday: 09:00 to 3:00p and Saturdays: By appointment.
Appointment *
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
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reason for Testing (ie Symptoms, Exposure, Event or Travel) *
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?
If this is a pre-operative test, when is your surgery or procedure?
What Covid Test are you interested in?

Rapid Covid-19 Antigen test ( Results in 15 minutes) Rapid Covid 19 Molecular NAAT Test (results in 30min) Rapid Covid PCR ($200 out of pocket fee, results in 45min)
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 scheduling your appointment!

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

Please wait in your car when you get to the clinic and call us at (763)496-5708 for further instructions
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COVID19 Appointment Request Questionnaire