Healthcare COVID-19 Questionnaire

HEALTHCARE COVID-19 QUESTIONNAIRE

This questionnaire is used to screen patients for signs of COVID-19 infection and potential exposure prior to providing healthcare services. The information provided will be used for clinical triage, infection control, and reporting to public health authorities when required. All answers must be complete and truthful.

Patient Information

Patient Name:

Insurance Information

Medical History

Screening Questions (within the last 14 days)

Please check all symptoms or conditions that apply:

Have you tested positive for COVID-19 within the past 90 days?

Have you had close contact with a confirmed COVID-19 case in the last 14 days?

Have you traveled outside your local area in the last 14 days? If yes, location and date(s):

Vaccination & Testing

COVID-19 vaccination status (enter number of doses received and date of most recent dose): Date of most recent dose:

I consent to COVID-19 testing and specimen collection as clinically indicated.

I authorize the facility to disclose test results to public health authorities and other healthcare providers as necessary for public health reporting and continuity of care.

Acknowledgment and Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that providing false information may affect my access to care and may have legal consequences. I understand that this questionnaire is a screening tool and does not constitute a definitive diagnosis.

I understand that I may withdraw consent for testing or data sharing at any time, subject to clinical and public health reporting requirements. I understand that the facility will retain records of this screening in accordance with applicable laws and medical record policies.

I acknowledge receipt of the facility's Privacy Notice regarding use and disclosure of my protected health information.

Additional Information

Sign Now