Patient Information
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Reservation Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Phone Number
Employee ID# (if applicable)
Reason for visit:
Communicable Disease Screening
In the last month, have you been in contact with someone who was confirmed or suspected to have Coronavirus / COVID-19?
Yes
Unable to assess
No/Unsure
Have you had a COVID-19 viral test in the last 14 days?
Yes - positive result
Yes - pending result
Yes - negative result
No
Unable to assess
Do you have any of the following new or worsening symptoms?
None of these
Unable to assess
Abdominal Pain
Bruising or bleeding
Chills
Cough
Diarrhea
Fatigue
Fever
Joint pain
Loss of smell
Loss of taste
Muscle pain
Rash
Red eye
Runny nose
Severe headache
Shortness of breath
Sore throat
Vomiting
Weakness
Have you travelled internationally in the last month?
Yes
No
Unable to assess
Submit
Should be Empty: