Patient Name
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Date of Birth
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Sex
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Address
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Email address
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Phone Number
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-
Area Code
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Race
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Multiple/Other
Ethnicity
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Unspecified
Fever >100.4F (38C)
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Unknown
Subjective Fever (felt feverish)
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Unknown
Chills
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Unknown
Muscle aches (myalgia)
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Unknown
Runny nose (rhinorrhea)
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Unknown
Sore throat
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Yes
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Unknown
Cough (new onset or worsening of chronic cough)
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Yes
No
Unknown
Shortness of breath (dyspnea)
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Yes
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Unknown
Nausea or vomiting
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Yes
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Unknown
Headache
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Yes
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Unknown
Abdominal pain
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Yes
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Unknown
Diarrhea (3 or more loose stools in 24 hours period)
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Unknown
Other symptoms, please specify
If no symptoms, reason for testing
PRE-EXISTING MEDICAL CONDITIONS
Chronic Lung Disease (asthma/ emphysema/COPD)
Yes
No
Unknown
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 (neurodevelopmental/intellectual disability)
Yes
No
Unknown
If female, currently pregnant?
Yes
No
Unknown
Current Smoker
Yes
No
Unknown
Former Smoker
Yes
No
Unknown
Other chronic diseases
Date of Visit
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Are you symptomatic as defined by CDC?
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If symptomatic, when did they begin?
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