WCP - Covid-19

Patient Name Patient Name * First Last
Patient DOB Patient DOB * / MM / DD YYYY
Which, if any, of the following symptoms are you experiencing? *

Which, if any, of the following symptoms are you experiencing? None Cough Headache Fatigue Diarrhea Vomiting Loss of taste Chills Fever Muscle aches Sore throat Nausea Loss of smell Persistent pain or pressure in chest New confusion or inability to arouse Bluish lips or face Runny nose or congestion Shortness of breath/trouble breathing
How long have you had the described symptoms, if any?
Have you been exposed to COVID-19 or traveled to a high risk location within the past 14 days? *

Have you been exposed to COVID-19 or traveled to a high risk location within the past 14 days? Yes No
Are you a health care worker or do you work in a health care setting? i.g. Acute care hospitals, Physicians' offices, Long-term care facilities (e.g., nursing homes, skilled nursing facilities, etc.), Urgent care centers, Outpatient clinics or centers, Emergency medical services, Home healthcare (i.e., care provided at home by professional health care providers) or Other medical clinics (including medical sites within non-healthcare settings such as in a school, dormitory, shelter, or prison). *

Are you a health care worker or do you work in a health care setting? i.g. Acute care hospitals, Physicians' offices, Long-term care facilities (e.g., nursing homes, skilled nursing facilities, etc.), Urgent care centers, Outpatient clinics or centers, Emergency medical services, Home healthcare (i.e., care provided at home by professional health care providers) or Other medical clinics (including medical sites within non-healthcare settings such as in a school, dormitory, shelter, or prison). Yes No
Are you the primary caretaker of family members and/or friends? *

Are you the primary caretaker of family members and/or friends? Yes No
Have you received the COVID-19 vaccine? *

Have you received the COVID-19 vaccine? Yes No Which vaccine have you received? Which vaccine have you received?
Which of the conditions below apply to you? *

Which of the conditions below apply to you? None Immunocompromised (cancer, HIV, immunosuppressant, etc.) Cardiovascular disease (heart attack, arrhythmia, stroke, etc.) Lung disease (COPD, asthma, lung fibrosis, etc.) Pregnancy Hypertension Diabetes Cirrhosis (liver scarring)
Name of Parent/Guardian Bringing Patient In Name of Parent/Guardian Bringing Patient In First Last
Which, if any, of the following symptoms are you experiencing?

Which, if any, of the following symptoms are you experiencing? Shortness of breath/trouble breathing Cough Headache Fatigue Diarrhea Vomiting Loss of taste Chills Fever Muscle aches Sore throat Nausea Loss of smell Persistent pain or pressure in chest New confusion or inability to arouse Bluish lips or face Runny nose or congestion
How long have you had the described symptoms, if any?
Have you been exposed to COVID-19 or traveled to a high risk location within the past 14 days?

Have you been exposed to COVID-19 or traveled to a high risk location within the past 14 days? Yes No
Are you a health care worker or do you work in a health care setting? i.g. Acute care hospitals, Physicians' offices, Long-term care facilities (e.g., nursing homes, skilled nursing facilities, etc.), Urgent care centers, Outpatient clinics or centers, Emergency medical services, Home healthcare (i.e., care provided at home by professional health care providers) or Other medical clinics (including medical sites within non-healthcare settings such as in a school, dormitory, shelter, or prison).

Are you a health care worker or do you work in a health care setting? i.g. Acute care hospitals, Physicians' offices, Long-term care facilities (e.g., nursing homes, skilled nursing facilities, etc.), Urgent care centers, Outpatient clinics or centers, Emergency medical services, Home healthcare (i.e., care provided at home by professional health care providers) or Other medical clinics (including medical sites within non-healthcare settings such as in a school, dormitory, shelter, or prison). Yes No