COVID Testing: Questions
Before your upcoming appointment with the doctor, please take time to fill out this form. It will be used by the physician to further decide which test is most suited for you.
Primary reason you are requesting COVID-19 antibody test
front line worker
caretaker for elderly or person with risk factors
personal medical risk factors such as diabetes, high blood pressure...
suspect you had exposure to COVID-19
living with someone who has high risk conditions more susceptible to infection
suspect that I had COVID-19 at some point, but did not get tested for it
Any recent travels to (or returning from) destination(s) in the last 60 days...
traveled to Europe
traveled to Asia
within the U.S. (excluding Hawaii and Alaska)
NO. I have not traveled
>>> (If yes), please list destination(s)
Any exposure to someone who has tested, confirmed positive for COVID-19?
Someone I suspect might have had it, but not tested, or the test result not yet available.
Have you been tested at all for COVID-19?
>>> If you answered "yes" to the prior Q, where and when did you get tested for COVID-19?
Please select the symptom(s) you have had
loss of taste or smell
abdominal pain, nausea, diarrhea
rash - blue/purple peeling of hands or toes
recent pink eye(s)
When did your symptom(s) start ? Please provide approximate date.
How long did your symptom(s) last? When did symptom(s) resolve?
Submit. This form will be encrypted and transmitted to Dr. Lai's office
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