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

CaucasianBlack/African AmericanAmerican Indian/Alaska NativeHawaiian/Pacific IslanderAsianUnknownOther
Ethnicity (Check all that apply)*

Hispanic/LatinoNon-Hispanic/LatinoArabNon-ArabUnknown
Worksite/School Name:
Occupation/Grade
Were you hospitalized for your COVID illness?

YESNO
Hospital Name:
City/Town Hospital is located:
Hospital Admission Date:

MonthDayYear
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)?*

YesNo
Did you have symptoms during your illness?

YesNo
If yes, when did your symptoms start?

MonthDayYear
Date
Date you were tested for COVID*

MonthDayYear
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 resultsNo, I did not notify anyoneNA
Please check all symptoms you experienced during your COVID illness:*

FeverRigors (A sudden feeling of cold with shivering and rise in temperature)CoughHeadachesFatigue/Lethargy/WeaknessDifficulty BreathingMuscle achesShortness of breathAbdominal painCongestionChest painConfirmatory chest x-ray or CAT scan for PneumoniaRunny noseNauseaDiarrhea (>3 loose/looser than normal stools/24 hour period)Loss of tasteChillsSore ThroatVomitingWheezingLoss of smellSeizureNONE of the above
My symptoms have all resolved:

YESNO
Date symptoms resolved (if applicable)

MonthDayYear
Date
Do you have any pre-existing conditions?

YesNoUnknown
Please check all that apply.

No pre-existing or chronic conditionsAsthma/Reactive Airway DiseaseChronic Liver DiseaseHypertensionAutoimmune conditionChronic Lung disease/COPD/EmphysemaNeurologic DiseaseOther Immunosuppressive ConditionCancerChronic Renal DiseaseSevere Obesity (BMI >40)Psychological/psychiatric conditionCardiovascular DiseaseDiabetes MellitusOther Chronic Disease
Please specify "other" condition.
Do you take any of the following medications?*

Aspirin or aspirin containing productsChemotherapyRadiation therapyOral steroidsOther immunosuppressive medicationsNone of the above
Please check if any of the following apply to you:*

I was pregnant at the time of my COVID illnessI am a current smokerI am a current vape userI am a current substance user (marijuana or other street drugs)I was a former smokerI was a former vape userI 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

MonthDayYear
Date
Has your workplace/school been notified*

YesNoNot Applicable
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:*

YESNO
Date isolation was started (isolation = no contact with any other individuals)*

MonthDayYear
Date
Do you know where you were exposed?*

YESNO
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.)*

YesNo
If yes, what type or name of the event?
Date of the event
Did you visit a restaurant/bar, school, college or other venue?*

YesNo
If yes, please give name of venue.
Date of the visit
Have you traveled?*

YesNo
If yes, where?
Date travel started:

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

YesNo
If yes, where?
Date travel started:

MonthDayYear
Date
Have you traveled within Michigan?*

YesNo
If yes, where?
Date travel started:

MonthDayYear
Date
Have you traveled on a cruise ship?*

YesNo
If yes, where?
Date travel started

MonthDayYear
Date
Did you travel on an airplane?*

YesNo
If yes, please list the dates if travel, airline name, flight numbers and seat locations
If patient is a student, has school been notified*

YesNoNot Applicable
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?

YesNo
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
Date
2. Contact Name

First NameLast Name
Relationship to contact:
Minor?

YesNo
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
Date
3. Contact Name

First NameLast Name
Relationship to contact:
Minor?

YesNo
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
Date
4. Contact Name

First NameLast Name
Relationship to contact:
Minor?

YesNo
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
Date
5. Contact Name

First NameLast Name
Relationship to contact:
Minor?

YesNo
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
Date
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: