COVID19
Please enter a patient ID code as instructed by your local site administrator and the patient's home ZIP code. Remember to give the patient ID code to the patient and have them bring it back if they return for another screening
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ZIP Code
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NPI Number (optional)
Do you have new onset cough?
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Yes
No
Do you have new onset fever?
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Yes
No
Are you short of breath?
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Yes
No
Have you noticed a loss of your sense of smell or taste?
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Yes
No
What is your age?
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What is your gender?
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Male
Female
Do you have a chronic medical condition? (i.e. Diabetes, Heart Disease, Immune Compromised)
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Yes
No
Are you pregnant?
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Yes
No
To the best of your knowledge, in the last month, have you had close contact with a person known to have COVID-19?
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Yes
No
Have you been tested for COVID-19?
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Yes, and negative
Yes, and positive
No, not tested
Submit