COVID19 Questionnaire
Consent
I agree to give my consent for information registration and other data processing of my personal and medical information.
Patient & Contact Information
First Name
Middle Name
Last Name
Suffix
Birthday
Sex
Please select
Male
Female
Prefer not to say
Mobile Number
Email
Address
Occupation
Symptoms within the last 14 Days
Cough
Colds
Sore Throat / Throat Pain
Shortness of Breath
Headache
Body Pains / Muscle Pains
Diarrhea with or without vomiting
Lack of smell or taste
Weakness
Fever 37.8°C or higher
Exposure History
Have you had any unprotected close contact exposure to a person confirmed COVID-19 positive?
No
Yes
Unprotected close contact - being within approximately six (6] feet or two (2] meters from a person with COVID-19 for approximately five (5] minutes or longer and not wearing a face mask.
Within the last 14 days, have you traveled via airplane internationally or domestically?
No
Yes
COVID-19 History
Have you been hospitalized or taken to a quarantine facility for pneumonia or COVID-19?
No
Yes
Have you tested positive for COVID-19?
No
Yes
Date tested
What is your reason for testing?
Please select
Work-related
Travel-related
Felt Flu-like Symptoms
Exposure to a person/s positive for COVID-19
Have you had Rapid Antibody Test for COVID-19?
No
Yes
Have you had RT-PCR (Swab test]?
No
Yes
Vaccination against COVID-19
Are you vaccinated against COVID19?
Please select
Yes, fully vaccinated
Yes, first dose only
No
Brand of vaccine
Informed Consent (Please write down your initials after each statement.)
I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the WHO. I give my consent to have treatment done to me during this pandemic.
I'm aware that the virus is extremely contagious, is believe to spread by person-to-person contact, may be transmitted by contact through surface, and that it can stay in the air for up to 72 hours. I'm also aware that it is not always possible to identify persons who are COVID-19 positive. To protect myself, other patients and the clinic staff, I therefore agree that treatment options available to me are limited only to urgent care.
I recognize that the clinic is adhering to strict infection control protocol/s for my protection and as such, I agree to cover the fee/s that this entails.
However, given the nature of the virus, I understand that there is higher risk of becoming infected with COVID-19 by traveling to and from the clinic, proceding with the treatment/procedure/surgery, and/or by simply staying in the clinic. Should I contract the virus, I hereby agree that I shall not hold the clinic, owner/s, or its staff liable.
I'm also giving my consent, in accordance to IATF rules, for my identity to be revealed and contact information shared for possible contact tracing.
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