MAP COVID-19 Screening

MAP COVID-19 Screening

Updated March 2021
Patient Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Which location is this screening for?*

Golden CampWalton WayKeysvilleWrensWaynesboroJ Dewey Gray Circle1111 Garredd Blvd1113 Garredd Blvd1115 Garredd BlvdWrightsboro RdInterstate Parkway

Have you had any of the following symptoms in the last 48 hours?*

	Yes	No
New or worsening cough
Shortness of breath of difficulty breathing
New loss of smell or taste
Unexplained fatigue/malaise
Fever, Chills and/or body aches

In the last 14 days have you:*

	Yes	No
Been in close contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

Are you currently isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?*

YesNo
Are you currently waiting on the results of a COVID-19 test? (Patient, Employee, or an accompanying guest)*

YesNo
Have you been hospitalized or on home quarantine for COVID-19 within the last 2 months? (Ill yourself, or caring for a sick family member)*

YesNo
Patient has answered “Yes” to one of the questions above, please DO NOT allow access into facility. Please follow the instruction set:

If the screening was conducted at the entrance of one of our facilities:
1. Contact the site Medical Assistant, Registered Nurse, Practice Manager or Provider for clearance to allow the patient into the facility.
2. Offer the patient the option of setting up a telehealth appointment.
If the screening was conducted over the phone:
1. Instruct the patient to stay at home and rest.
2. Offer patient the option of a telehealth option and schedule if applicable.
3. If telehealth appointment is not an option please contact the medical staff for futher instructions.
Patient/Employee has answered NO to all questions. The patient/employee is allowed access to facility.
Should be Empty: