Covid-19 Antigen Intake Form
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Other
Passport Number
For Travelers
Race
Please Select
AmericanIndian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Please Choose the one Describe You the Best
Are you pregnant or may be a pregnant?
Yes
No
Do you regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)
Yes
No
Have you possibly been exposed to the Coronavirus in the past 2 weeks?
Yes
No
Do you live, work or have visited a place where COVID-19 is widespread.
Yes
No
Do you suffer from any following conditions?
High blood pressure
Heart disease (e.g. previous heart attacks, heart failure, etc.)
Diabetes
Overweight or obesity
Kidney disease or Dialysis
Previous stroke or other neurological condition affecting my ability to cough
Liver disease
Lung disease
NONE OF THE ABOVE
Do you have a condition that weakens my immune system or makes it harder to fight infections
HIV
Cancer
Lupus
Rheumatoid Arthritis
Solid organ or bone marrow transplant
NONE OF THE ABOVE
Are you taking one of these medications?
Steroids
Chemotherapy
Immunosuppressants
NONE OF THE ABOVE
Have you had any of the following symptoms since December 2019?
Fever, at least 100.3 F
Dry cough, new or worsening
Sinusitis or sinus pain
Loss of smell or taste
Runny nose or stuffy nose
Chills
Feeling tired, fatigue
Headache
Sore throat, new or worsening
Shortness of breath, particularly with simple activities
Muscle pain/aches or joint pain
Diarrhea
Vomiting
Red/purple bumps on hands or toes/feet, painful or sore to touch
Pink eye
Expectoration (ex phlegm or mucous)
NONE OF THE ABOVE
Currently, are you experiencing any of the symptoms described in previous questions?
Yes
No
Have you been in close proximity (within 6 ft.) to someone who is sick?
Yes
No
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: