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QUESTIONNAIRE – El Paso
Case ID El Paso
Case ID Mission
Case ID San Antonio
Name*
*
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Last
Cell#
*
Date of Birth
*
MM slash DD slash YYYY
Age
Address
*
Address
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Select an option
*
Fully Vaccinated
Not fully vaccinated
Not vaccinated
Completed 2 weeks after 2nd dose, Pfizer or Moderna, or single dose of Johnson & Johnson of COVID-19 vaccine has been administered.
Pfizer
Moderna
Johnson and Johnson
Date of 1st dose
MM slash DD slash YYYY
Date of 2nd dose
MM slash DD slash YYYY
2. Have you traveled in the past 10 days?
Yes
No
3. Have you experienced any COVID-19 symptoms or had been ill within the past 10 days?
Yes
No
If yes please mark the symptoms below:
CDC Symptoms
Cough
Shortness of breath
Or at least 2 of these symptoms
Fever
Chills
Repeated shaking with chills
Muscle Pain/Body aches
Congestion or Runny nose
Headache
Sore Throat
New loss of taste and/or smell
Fatigue
Nausea or Vomiting
Diarrhea
4. Have you lived or been in close contact with someone that has been diagnosed with COVID-19 within the past 10-days?
Yes
No
When was the last known date of contact?
5. Do you agree to take temperature at the time of appointment?
Yes
No
6. Do you agree to wear your mask during the appointment?
Yes
No
Answering "NO" to #5 & #6 will require rescheduling to adhere of office policy.
Temperature taken at the time of appointment
I
, attest that the information provided in this form is accurate and true to the best of my knowledge. I understand that (Print first and last name) knowingly making a false statement on this form is a crime and can be punished by fine or imprisonment or both (HRS§ 710-1063).
Caregiver/Care Recipient signature:
PATIENT RECORD FORM
Date of Service:
MM slash DD slash YYYY
Medical Record # (office use):
Sex:
Male
Female
Name
First
Last
Cell #:*
Data added automatically, no further action required.
DOB:*
MM slash DD slash YYYY
Data added automatically, no further action required.
Address:
Data added automatically, please update if required.
City:
Data added automatically, no further action required.
State
Select a state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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Kentucky
Louisiana
Maine
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Massachusetts
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Minnesota
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New York
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North Dakota
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Data added automatically, no further action required.
Zip Code
Data added automatically, no further action required.
Insurance:
ID Type (SSN, State ID, No ID, Foreign ID)
*
SSN
State ID
No ID
Foreign ID
Patient ID:
Group ID:
Driving Lic.
**SELECT IF NO INSURANCE**
Location:
RGV
SAN ANTONIO
EL PASO
This schedule will be filed under the location selected above.
Reason for Testing
Exposure
Symptoms
Recent Positive
SERVICES PERFORMED
COVID TEST
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Remove
Notes
Laboratory Results
Test Name
Result
Lot Number
N/A
Covid19 Antigen Rapid Test
Covid19 Rapid Antibody Test
Covid/Flu A&B Antigen Test
N/A
POSITIVE
NEGATIVE
Add
Remove
Attendant Name
Hossain Tarif
Arafat1
James Abenoja
Att Signature
no action required
Billing TIN Number
Patient Account Number
