Covid-19 Case Details

Covid-19 Case Details
IMPORTANT: Please complete this form if you have tested positive for COVID19. If you have tested negative and/or have had no symptoms DO NOT complete this form.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What County do you live in? *
Preferred Phone Number *
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
Parent/Guardian (required if under 18)

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender (Given at birth) *
Race (Check all that apply) *

Caucasian Black/African American American Indian/Alaska Native Hawaiian/Pacific Islander Asian Unknown Other
Ethnicity (Check all that apply) *

Hispanic/Latino Non-Hispanic/Latino Arab Non-Arab Unknown
Worksite/School Name:
Occupation/Grade
Were you hospitalized for your COVID illness? *

YES NO
Hospital Name:
City/Town Hospital is located:
Hospital Admission Date:

Month Day Year
Date
Check yes if you'd like us to email you resources regarding self isolation or quarantine for your close contacts.

Yes, please email me resources
Were you in quarantine when your symptoms started (or at the time of your test if no symptoms)? *

Yes No
Did you have symptoms during your illness? *

Yes No
If yes, when did your symptoms start?

Month Day Year
Date
Date you were tested for COVID *

Month Day Year
Date
Where did you get your test done? (Please be specific with name and location, ie Meijer in Alma, Acme Urgent care on Main St., I tested at home etc.) *
If your test was performed at home, did you notify your Primary Care Provider of the results? *

Yes, I sent in my results No, I did not notify anyone NA
Please check all symptoms you experienced during your COVID illness: *

Fever Rigors Cough Headaches Fatigue/Lethargy/Weakness Difficulty Breathing Evidence of Pneumonia Multi-Organ Dysfunction Syndrome (MODS) Muscle aches Shortness of breath Abdominal pain Congestion Chest pain Confirmatory chest x-ray or CAT scan for Pneumonia Acute Respiratory Distress Syndrome (ARDS) Runny nose Nausea Diarrhea (>3 loose/looser than normal stools/24 hour period) Encephalopathy/Encephalitis Loss of taste Toxic state (sepsis) Chills Sore Throat Vomiting Wheezing Loss of smell Seizure Stroke/Venus Thromboembolism (VTE) NONE of the above
My symptoms have all resolved: *

YES NO
Date symptoms resolved (if applicable)

Month Day Year
Date
Do you have any pre-existing conditions? *

Yes No Unknown
Please check all that apply. *

No pre-existing or chronic conditions Asthma/Reactive Airway Disease Chronic Liver Disease Hypertension Autoimmune condition Chronic Lung disease/COPD/Emphysema Neurologic Disease Other Immunosuppressive Condition Cancer Chronic Renal Disease Severe Obesity (BMI >40) Psychological/psychiatric condition Cardiovascular Disease Diabetes Mellitus Other Chronic Disease
Please specify "other" condition.
Do you take any of the following medications? *

Aspirin or aspirin containing products Chemotherapy Radiation therapy Oral steroids Other immunosuppressive medications None of the above
Please check if any of the following apply to you: *

I was pregnant at the time of my COVID illness I am a current smoker I am a current vape user I am a current substance user (marijuana or other street drugs) I was a former smoker I was a former vape user I was a former substance user (marijuana or other street drugs) None of the above
Where were you staying at the time of illness onset (Or at the time of positive for asymptomatic individuals)? *
Do you live or work in one of the following? *
If you're a healthcare worker, what is your occupation? *
If you're a healthcare worker, what is your job setting? *
Name of workplace(s) if applicable.
Name of school(s) you attend, if applicable.
Date last worked/attended school

Month Day Year
Date
Has your workplace/school been notified *

Yes No Not Applicable
Address of workplace/school (If applicable)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address of ADDITIONAL workplace/school (if needed)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date isolation was started (isolation = no contact with any other individuals) *

Month Day Year
Date
I am not able to isolate away from others:

YES (I cannot isolate away from others) NO (I am able to complete isolate away from others)
Do you know where you were exposed? *

YES NO
How (or by whom) were you exposed (if unknown type NA) *
In the 2 weeks prior to your symptoms starting (or date of test if no symptoms) did you:
Attend a community event or mass gathering? (e.g. concert, rally, parade, wedding, sporting event, etc.) *

Yes No
If yes, what type or name of the event?
Date of the event
Did you visit a restaurant/bar, school, college or other venue? *

Yes No
If yes, please give name of venue.
Date of the visit
Have you traveled to a non-U.S. country? *

Yes No
If yes, where?
Date travel started:

Month Day Year
Date
Have you traveled in the U.S. outside of your home state? *

Yes No
If yes, where?
Date travel started:

Month Day Year
Date
Have you traveled within Michigan? *

Yes No
If yes, where?
Date travel started:

Month Day Year
Date
Have you traveled on a cruise ship? *

Yes No
If yes, where?
Date travel started

Month Day Year
Date
Did you travel on an airplane? *

Yes No
If yes, please list the dates if travel, airline name, flight numbers and seat locations
If patient is a student, has school been notified *

Yes No Not Applicable
How (or by whom) were you exposed *
Have you received a COVID vaccine? *
List Close Contacts Here

IMPORTANT: Your close contacts must quarantine. They should quarantine for 14 days from the last contact with the COVID positive person (while they were considered contagious).

If close contact tests negative, they still must complete the quarantine since symptoms may appear 2 to 14 days after exposure to the virus.

A close contact is someone who was closer than 6 feet, for 15 minutes or more -this is cumulative time throughout the day- with or without masks to the COVID -19 positive person during their contagious period.

The contagious period begins 2 days before symptoms start, (or 2 days before testing if no symptoms) and goes until the positive person was isolated from others.

Any time a new household member gets sick with COVID-19, they will need to restart the quarantine period. If they cannot avoid close contact with the person who has COVID-19, their quarantine will start only after the person who has COVID-19 meets the criteria to end home isolation. This could mean household contacts may be in quarantine for 24 days or more! If they can quarantine away from you, they should!

Contacts of a contact do not need to quarantine but should monitor themselves for symptoms.

It is recommended for close contacts of a positive case to wait 5-7 days after exposure to obtain testing if asymptomatic.
1. Contact Name

First Name Last Name
Relationship to contact
Minor?

Yes No
Please indicate what school the child attends & if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

Month Day Year
Date
2. Contact Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Please indicate what school the child attends & if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

Month Day Year
Date
3. Contact Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Please indicate what school the child attends & if he/she is virtual or in person learning
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

Month Day Year
Date
4. Contact Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Please indicate what school the child attends & indicate if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

Month Day Year
Date
5. Contact Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Please indicate what school the child attends & if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

Month Day Year
Date
Please add additional close contacts or any other information you think we need to know.
Should be Empty:

Covid-19 Case Details

In the 2 weeks prior to your symptoms starting (or date of test if no symptoms) did you: