Healthcare PSQ Form

HEALTHCARE PSQ FORM

Patient Information

Emergency Contact

Insurance Information

Medical History

Screening & Symptoms

In the past 14 days, have you experienced any of the following? Check all that apply.

Have you had a positive test for a communicable illness in the last 30 days? Yes No

Lifestyle / Safety

Vaccination / Testing

COVID-19 vaccination status: Unvaccinated Partially vaccinated Fully vaccinated

Authorization & Privacy Acknowledgment

I certify that the information I have provided on this Patient Screening Questionnaire is true and complete to the best of my knowledge. I authorize healthcare personnel to use this information for treatment, care coordination, and billing purposes. I understand that this authorization to use and disclose protected health information for the purposes described will remain in effect until revoked in writing.

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices which describes how my health information may be used and disclosed, and my rights regarding that information. I understand that I may request restrictions on certain uses and disclosures and that such requests will be considered in accordance with applicable law.

This authorization expires on:

Additional Information / Clinician Use

Certification

By signing below I certify that the information contained in this form is accurate and complete to the best of my knowledge. I consent to necessary examination and treatment. I understand that intentional falsification or omission of material information may affect clinical decisions and may be subject to institutional policies. I understand I may revoke this authorization at any time by providing a written notice to the facility, except to the extent that action has already been taken in reliance on this authorization.

Sign Now