HAZLET PHARMACY POCT Covid Antigen Testing

Point of Care Testing for COVID19
Patient Intake and Assessment Form
2874 Highway 35 Hazlet, NJ 07730
Patient Name*
Gender*
MaleFemale
Birth Date*
MonthDayYear
1
Address*
Patient Address
Street Address Line 2
City/State/ZipState / Province
Postal / Zip Code
Patient Phone Number*
Patient Weight
Primary Care Physician
Physician Phone Number
Please enter a valid phone number.
Physician Address
Medication Allergies
Current Medications
Past Medical History
Current Situation When did your symptoms start?
Date exposed to COVID 19 (if known)?
MonthDayYear
Date
Which of these symptoms do you currently have?
Fever?*
YesNo
What temperature?
Cough?*
YesNo
Vomiting?*
YesNo
Diarrhea?*
YesNo
Shortness of Breath?*
YesNo
Chills?*
YesNo
Sore Throat?*
YesNo
Muscle Pain?*
YesNo
New loss of Taste or Smell?*
YesNo
Have you taken any medications for these symptoms?*
YesNo
If yes, what have you taken, and when?
Do you have any of the following medical conditions?
Asthma or Chronic Lung DiseaseSerious Heart Condition, such as Congestive Heart FailureDiseases or conditions that make it harder to coughKidney Failure or End Stage Renal DiseaseConditions that result in a weakened immune system, including Cancer treatmentsDiabetesPregnancyExtreme ObesityCirrhosis
Have you been prioritized by your local health department for testing?*
YesNo
Are you a health care worker, first responder, or law enforcement officer?*
YesNo
Do you live or work in a treatment facility, group home, or other group setting?*
YesNo
Are you a caregiver for an elderly person or someone with a weakened immune system?*
YesNo
Should be Empty: