COVID-19 Patient Screening Form

Patient Name*

First Last

Patient Age*

Phone

Email

Q1: Are you fully vaccinated against COVID-19 and / or aged 11 or younger?*

Select "No" if you are immunocompromised.

Yes
No

Q2: In the last 14 days have you been directed by a border agent to comply with federal quarantine requirements due to international travel?*

Select "No" if all of the following apply: You have completed your isolation period, you tested negative for COVID-19 on one PCR test or rapid molecular test or two rapid antigen tests taken 24 to 48 hours apart, you do not have a fever, and your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea).

Yes
No

Q3: In the last 5 days (if fully vaccinated) / 10 days (if unvaccinated or immunocompromised), have you experienced any of these symptoms?*

Select "None of the above" if you are 18 or older and have received your booster dose, you are 17 or younger and are fully vaccinated, and you completed your isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test).

Q4: Do any of the following apply?*

Select "None of the above" if you have already completed your isolation period because your symptoms started before your positive test result, you do not have a fever, and your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea)

Select All
You live with someone who is currently isolating because of a positive COVID-19 test
You live with someone who is currently isolating because of COVID-19 symptoms
You live with someone who is isolating while waiting for COVID-19 test results
None of the above

Q5: In the last 5 days (if fully vaccinated)/ 10 days (if unvaccinated or immunocompromised), have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?*

Yes
No

Q6: Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*

Yes
No

Patient Signature*

Comments

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