COVID SCREENING FORM
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Date of Birth
*
Sex
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Social Security Number
Phone Number
*
Race
Please Select
-- Please Select --
American Indian
Alaskan Native
Asian
Black or African American
Native Hawaiian
Other Pacific Islander
White
Multiple/Other
Ethnicity
Please Select
-- Please Select --
Hispanic/Latino
Non-Hispanic/Latino
Unspecified
Fever >100.4F (38C)
Please Select
-- Please Select --
Yes
No
Unknown
Subjective Fever (felt feverish)
Please Select
-- Please Select --
Yes
No
Unknown
Chills
Please Select
-- Please Select --
Yes
No
Unknown
Muscle aches (myalgia)
Please Select
-- Please Select --
Yes
No
Unknown
Runny nose (rhinorrhea)
Please Select
-- Please Select --
Yes
No
Unknown
Sore throat
Please Select
-- Please Select --
Yes
No
Unknown
Cough (new onset or worsening of chronic cough)
Please Select
-- Please Select --
Yes
No
Unknown
Shortness of breath (dyspnea)
Please Select
-- Please Select --
Yes
No
Unknown
Nausea or vomiting
Please Select
-- Please Select --
Yes
No
Unknown
Headache
Please Select
-- Please Select --
Yes
No
Unknown
Abdominal pain
Please Select
-- Please Select --
Yes
No
Unknown
Diarrhea (3 or more loose stools in 24 hours period)
Please Select
-- Please Select --
Yes
No
Unknown
Other symptoms, please specify
If no symptoms, reason for testing
Pre-existing Medical Conditions
Chronic Lung Disease
Yes
No
Unknown
(asthma/emphysema/COPD)
Diabetes Mellitus
Yes
No
Unknown
Cardiovascular disease
Yes
No
Unknown
Chronic renal disease
Yes
No
Unknown
Chronic liver disease
Yes
No
Unknown
Immunocompromised Condition
Yes
No
Unknown
Neurological disability
Yes
No
Unknown
(neurodevelopmental/intellectual disabilty)
If female, currently pregnant
Yes
No
Unknown
Current smoker
Yes
No
Unknown
Former smoker
Yes
No
Unknown
Other chronic diseases
Date of Visit
-
Month
-
Day
Year
Date
Enter name for consent
*
Insurance Information
Include for laboratory billing to avoid bill from lab company
Name of Insurance Company
Insurance Address
Card Holder Name, DOB, relationship to patient
Insurance ID Number
Insurance Group Number
Is this your first COVID-19 Test?
*
Please Select
-- Please Select --
Yes
No
Are you employed in Healthcare?
*
Please Select
-- Please Select --
Yes
No
Are you symptomatic as defined by CDC?
*
Please Select
-- Please Select --
Yes
No
If symptomatic, when did they begin?
*
Have you been hospitalized for COVID-19?
*
Please Select
-- Please Select --
Yes
No
Have you been in ICU for COVID-19?
*
Please Select
-- Please Select --
Yes
No
Are you a resident in a congregate care setting?
*
Please Select
-- Please Select --
Yes
No
Are you pregnant?
*
Please Select
-- Please Select --
Yes
No
Other chronic diseases
Payment - Select Option Leave Unchecked if Paying Cash/Check
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Lab Testing Admin Fee
$
20.00
Lab Testing Send Off Only
Rapid Covid Onsite Testing
$
100.00
Rapid Testing Only
Total
$
0.00
Credit Card
Appointment
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