COVID19 Screening Contact Info Your Name (required) Date of Birth (required) Age (required) Height Weight Your Email (required) Your Address (required) Your City(required) State*AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVIVTWAWIWVWY Your Zip (required) Phone: Make and Color of your Car Chief complaint/HPI : Coronavirus screening Are you worried about COVID-19?YesNo Are you experiencing fever or feel feverish?YesNo Are you having shakes/chills? YesNo Are you experiencing a cough? YesNo Are you experiencing shortness of breath? YesNo Are you having chest pressure/pain? YesNo Are you experiencing sore muscles? YesNo Are you experiencing loss of smell/taste? YesNo Are you experiencing headaches? YesNo Are you having a sore throat? YesNo Are you experiencing diarrhea? YesNo Are you experiencing nausea/vomiting? YesNo Do you have diabetes? YesNo Do you have high blood pressure? YesNo Do you have any heart/vascular disease? YesNo Do you have any respiratory disease? YesNo Do you have a low immune system? YesNo If female, are you pregnant? YesNo In the past 14 days, have you had contact with anyone suspected or known to have coronavirus, COVID-19? YesNo Are you a healthcare worker who has been within 6 feet of a patient suspected of COVID-19 infection or have an occupation where you are in close contact with large numbers of people each day? YesNo Do you live with, or frequently interact with people who are older than 60 years of age or who have chronic medical conditions (including cancer, heart disease, COPD, asthma, or immune disorders)? YesNo I consent for the COVID-19 evaluation and testing. I authorize the release of medical information that is necessary for my further treatment. I authorize the release of information, including treatment and protected health information to my insurance company that is needed to process payment for services. I authorize my insurance carrier to pay benefits for services rendered directly to PHS-Preventive Health solutions or any of its affiliates. Δ
