COVID19 Screening

    Contact Info


    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