Healthcare Symptom Review Questionnaire

Healthcare Symptom Review Questionnaire

This questionnaire is intended to document current symptoms, recent exposures, and relevant medical history to inform clinical assessment and treatment. All information provided is protected health information and will be used in accordance with applicable privacy and confidentiality obligations.

Patient Information

Date of Birth:    Gender: Female Male Other

Emergency Contact

Insurance Information

Current Medications & Allergies

Medical History (check all that apply)

Diabetes    Hypertension    Asthma / COPD    Heart disease

Immunosuppressed    Kidney disease    Liver disease    None of the above

Symptom Checklist

For each symptom present, check the box and indicate date of onset and severity (1 = mild, 10 = severe).

Fever or chills    Onset:   Severity:

Cough    Onset:   Severity:

Shortness of breath or difficulty breathing    Onset:   Severity:

Sore throat    Onset:   Severity:

Nausea, vomiting or diarrhea    Onset:   Severity:

New loss of taste or smell    Onset:   Severity:

Vital & Exposure Information

Have you measured your temperature today? Yes No    If yes, highest recorded temperature:

In the last 14 days, have you had close contact with a person known to be infected with a contagious respiratory illness? Yes No

Yes    No

Testing & Vaccination

Have you tested positive for a contagious respiratory illness in the past 30 days? Yes No

Vaccination status for relevant respiratory pathogens: Up to date Partially vaccinated Not vaccinated

Patient Statement, Authorizations & Acknowledgments

I certify that the information I have provided on this questionnaire is true and accurate to the best of my knowledge. I understand that intentionally providing false information may delay or adversely affect my care and may be subject to administrative action.

I acknowledge that my clinician may use the information on this form to determine clinical urgency, to recommend testing or treatment, and to implement infection control measures when appropriate. I authorize release of this information to other healthcare providers involved in my care for the purpose of diagnosis and treatment.

I understand that I may withdraw consent for use and disclosure of my information to the extent permitted by law, except to the extent that action has already been taken in reliance on this information.

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