COVID-19 Patient Screening Form

Name

First NameLast Name

National Security Number

Birth Date

MonthDayYear

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

COVID-19 Test Date

Date

COVID-19 Test Result

PendingPositiveNegative

If you are experiencing any symptoms related to coronavirus, make sure you comply with preacutionary measures such as physical distancing, wearing a mask, keeping rooms well ventilated, avoiding crowds, cleaning your hands, and coughing into a bent elbow or tissue until you recieve your test result.

If you are tested positive:

- Stay home and seperate yourself from other people

- Take necessary steps to prevent the spreading of Coronavirus

- Use your medication and follow the instructions

If you are tested negative, comply with precautionary and healthcare measures to prevent the spreading of Coronavirus.

Symptoms

Temperature

Did you receive medication?

YesNo

Day of Medication