Healthcare Screening Documents

HEALTHCARE SCREENING DOCUMENTS

This screening document collects essential demographic, medical history and exposure information to evaluate suitability for clinical services and to support appropriate infection control measures. Provide complete and accurate responses. Deliberate misrepresentation may affect clinical care and is subject to applicable laws and facility policy.

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to disclose

Emergency Contact

Insurance / Payer Information

Screening / Presenting Complaint

Date of Screening:

Current Symptoms (check all that apply)

Fever or chills    Cough    Shortness of breath    Sore throat

Loss of taste or smell    Nausea or vomiting    Diarrhea    Rash

None of the above

Exposure & Travel History

In the past 14 days, have you had close contact with a person known to have a communicable infectious disease?    Yes    No

Travel outside the local area in the past 14 days?    Yes    No

Medical History

Pregnancy status (if applicable):    Pregnant    Not pregnant    Unknown

Tobacco use:    Current smoker    Former smoker    Never smoker

Immunization / Testing History

Recent influenza vaccination: Yes    No    If yes, date:

COVID-19 vaccination: Yes    No    If yes, last dose date:

Authorization & Consent for Screening

I authorize the facility and its clinical staff to perform screening procedures, collect specimens, and to administer or arrange diagnostic testing as clinically indicated. I understand that screening and testing results may be used to inform my care, to implement infection control measures, and may be disclosed to public health authorities when required by law.

I acknowledge that results of testing are part of my medical record. The facility will make reasonable efforts to protect my health information in accordance with privacy practices, but I understand that certain disclosures may be required by law. I may refuse or withdraw this authorization at any time by notifying the facility in writing; however, withdrawal will not affect actions already taken in reliance on this authorization.

By signing below I certify that the information I have provided on this screening document is true and complete to the best of my knowledge. I understand that providing false information may affect the care provided or have legal consequences where applicable.

Privacy Acknowledgment

I acknowledge receipt of the facility's privacy practices notice and understand how my health information may be used and disclosed for treatment, payment, healthcare operations, and public health reporting as required by law. I authorize the facility to communicate results and relevant health information to the emergency contact listed above if clinically necessary.

Acknowledgement of Privacy Notice:    I acknowledge receipt    I decline to acknowledge

Additional Instructions / Provider Use

Certification: I attest under penalty of perjury that the information provided on this screening form is true and correct. I understand that this screening does not constitute comprehensive medical evaluation and that additional assessment, testing, or referral may be required based on clinical judgment.

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