COVID 19 Self Assessment Questionnaire

COVID19 Appointment Request Questionnaire

This questionnaire is completed online.
Name

First Name Last Name
Date of Birth
Sex
Phone No. and Email
Address
Reason for Testing
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
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 filling our appointment request form.

Please look out for an enrollment form from our EMR AtlasMD for our intake forms.

Kindly complete all the necessary information to help expedite your appointment.
Should be Empty:

COVID19 Appointment Request Questionnaire