COVID-19 Screening

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COVID-19 Screening

Please fill out theform below.
When you arrive at the building, please wait in your car or in the building lobby. We will text when the clinic has been cleared for you to come into the clinic.
You will need to wash your hands before the appointment begins.
If you have a mask, you are encouraged to wear it during your appointment.

Patient Full Name *

Patient Email Address *

Is this an emergency?

Stop and call 911 if you are experiencing:

-Severe, constant chest pain or pressure
-Extreme difficulty breathing
-Severe, constant lightheadedness
-Serious disorientation or unresponsiveness

Are you experiencing any of the symptoms above? *

I'm experieincing at least one of these

I do not have any of these

How old are you? *

Under 18

Between 18 and 64

65 or older

Are you experiencing any of these symptoms? Select all that apply *

Fever, chills or sweating

Difficulty breathing (not severe)

New or worsening cough

Sore throat

Aching throughout the body

Vomiting or diarrhea

None of the above

Required

Do you have any of these conditions? Select all that apply *

Asthma or chronic lung disease

Pregnancy

Diabetes with complications

Diseases or conditions that make it harder to cough

Kidney failure that needs dialysis

Cirrhosis of the liver

Weakened immune system

Congestive heart failure

Extreme obesity

None of the above

Required

In the last 14 days have you traveled internationally? *

I have traveled internationally

I have not traveled internationally

In the last 14 days, have you been in an area where COVID-19 is widespread? Select all that apply *

I live in an area where COVID-19 is widespread

I have visited an area where COVID-19 is widespread

I don’t know

None of the above

Required

In the last 14 days, what is your exposure to others who are known to have COVID-19? *

I live in with someone who has COVID-19

I’ve had close contact with someone who has COVID-19 (for 10 minutes, I was within 6 feet of someone who’s sick or exposed to a cough or sneeze).

I’ve been near someone who has COVID-19 (I was at least 6 feet away and was not exposed to a sneeze or cough)tion 3

I’ve had no exposure (I have not been in contact with someone who’s sick.)

Do you live or work in a care facility? *

I live in a long-term care facility

I have worked in a hospital or other care facility in the past 14 days

I plan to work in a hospital or other care facility in the next 14 days

No, I don’t live or work in a care facility

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