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 NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What County do you live in?
Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Parent/Guardian (required if under 18)

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender (Given at birth)
Race (Check all that apply)
Ethnicity (Check all that apply)
Worksite/School Name:
Occupation/Grade
Were you hospitalized for your COVID illness?
Hospital Name:
City/Town Hospital is located:
Hospital Admission Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Check yes if you'd like us to email you resources regarding self isolation or quarantine for your close contacts.
Were you in quarantine when your symptoms started (or at the time of your test if no symptoms)?
Did you have symptoms during your illness?
If yes, when did your symptoms start?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date you were tested for COVID

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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?
Please check all symptoms you experienced during your COVID illness:
My symptoms have all resolved:
Date symptoms resolved (if applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have any pre-existing conditions?
Please check all that apply.
Please specify "other" condition.
Do you take any of the following medications?
Please check if any of the following apply to you:
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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has your workplace/school been notified
Address of workplace/school (If applicable)

Street Address

Street Address Line 2

CityState / Province

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am able to isolate away from others:
Date isolation was started (isolation = no contact with any other individuals)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you know where you were exposed?
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.)
If yes, what type or name of the event?
Date of the event
Did you visit a restaurant/bar, school, college or other venue?
If yes, please give name of venue.
Date of the visit
Have you traveled?
If yes, where?
Date travel started:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you traveled in the U.S. outside of your home state?
If yes, where?
Date travel started:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you traveled within Michigan?
If yes, where?
Date travel started:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you traveled on a cruise ship?
If yes, where?
Date travel started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Did you travel on an airplane?
If yes, please list the dates if travel, airline name, flight numbers and seat locations
If patient is a student, has school been notified
How (or by whom) were you exposed
Have you received a COVID vaccine?
IMPORTANT: Your close contacts should quarantine. The quarantine period starts from the last date of contact with the COVID positive person (while they were considered contagious). This date is considered day 0.

If close contact tests negative, they still must complete the quarantine.

For the most current guidelines for Quarantine and Isolation, please visit our website www.mmdhd.org/covid-testing

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. 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 days after exposure to obtain testing if asymptomatic.
1. Contact Name

First NameLast Name
Relationship to contact
Minor?
Please indicate what school the child attends & if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2. Contact Name

First NameLast Name
Relationship to contact:
Minor?
Please indicate what school the child attends & if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
3. Contact Name

First NameLast Name
Relationship to contact:
Minor?
Please indicate what school the child attends & if he/she is virtual or in person learning
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
4. Contact Name

First NameLast Name
Relationship to contact:
Minor?
Please indicate what school the child attends & indicate if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
5. Contact Name

First NameLast Name
Relationship to contact:
Minor?
Please indicate what school the child attends & if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
(If known) county of residence
Date this person was last in contact with you (this determines the quarantine period)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please add 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: