New Patient Assessment

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New Patient Assessment

New Patient Assessment

21Questions

Language

English (US)

1
Form_Start_DateTime
2
Before we get started, how did you learn about our testing services?* This field is required.
Google Search
Google Ads
Facebook Ad
Facebook
Family/Friend
PrincetonCovid.org
InterFaith RISE
Poster/Flyer
Postcard
Other
3
If other, where did you find usWe like to know so we can connect with more great people like you
4
Is this your first time being test for COVID-19?* This field is required.
YESNO
5
Why are you seeking a COVID-19 test?* This field is required.
Mild Flu-like Symptoms
Exposure to someone with COVID-19
Travel
Pre-Procedure
School
Sports
Work Requirement
Other
6
If other, please share your reason for the test
7
Are you a Healthcare worker?* This field is required.
YESNO
8
Have you ever been hospitalized for your symptoms?* This field is required.
YESNO
9
Have you ever been in the ICU for your symptoms?* This field is required.
YESNO
10
Are you a resident in a congregate care setting (including nursing homes, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting)?* This field is required.
YESNO
11
Patient First Name* This field is required.
12
Patient Last Name* This field is required.
13
Patient Birth Date* This field is required.mm-dd-yyyy
14
Passport Number (For Travel Only)
15
Race (Required for CDC reporting)One or more categories may be selected
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Asian
Hispanic or Latino
White
16
Ethnicity: Are you Hispanic, Latino/a, or Spanish origin? (Required for CDC reporting)One or more categories may be selected
Mexican
Puerto Rican
Mexican American
Cuban
Chicano/a
Another Hispanic, Latino/a, or Spanish origin
Not of Hispanic, Latino/a, or Spanish origin
Unknown
17
Input Health Insurance (If you have choosen an insurance covered test)
Insurance Name
Member ID #
Group ID #
Plan Name
18
What is your Primary Care Physician's Full Name?
19
What is your Primary Care Physician's Phone Number?
Area Code
Phone Number
20
Do you have any of the following life threatening symptoms?* This field is required.
Yes
No
Bluish /ˈblo͞oiSH/ lips or face
Severe pain or pressure in the chest
Extreme difficulty breathing (gasping for air or cannot talk without catching your breath)
Severe dizziness or lightheadedness
Severe Confusion
Difficulty waking up or staying awake
Slurred speech (new or worsening)
Signs of low blood pressure (too weak to stand, light headed, feeling cold, pale, clammy skin)
Bluish /ˈblo͞oiSH/ lips or face
Severe pain or pressure in the chest
Extreme difficulty breathing (gasping for air or cannot talk without catching your breath)
Severe dizziness or lightheadedness
Severe Confusion
Difficulty waking up or staying awake
Slurred speech (new or worsening)
Signs of low blood pressure (too weak to stand, light headed, feeling cold, pale, clammy skin)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1 of 8
21
Bluish lips or face
22
Severe pain or pressure in the chest
23
Extreme difficulty breathing
24
Severe dizziness or lightheadedness
25
Confusion
26
Difficulty waking up or staying awake
27
Slurred speech
28
Signs of low blood pressure
29

COVID-19 EMERGENCY ACTION

You have answered 'Yes' to a potentially life-threatning sympton. It is recommended that you call 911 or have someone drive you to the nearest Hosiptal Emergency Department immediately. If the physicians are concerned they may test you for COVID-19 there.

Please Seek Medical Attention Immediately
30
Please select whether you've experienced/are experiencing the following mild symptoms* This field is required.
Yes
No
Mild difficulty breathing or wheezing
New loss of taste or smell
Headache
Fever
Muscle aches or body aches
Cough
Sore Throat or Stuffy Nose
Feeling unwell, fatigue or severe exhaustion
Nausea, Vomiting or Diarrhea
Mild difficulty breathing or wheezing
New loss of taste or smell
Headache
Fever
Muscle aches or body aches
Cough
Sore Throat or Stuffy Nose
Feeling unwell, fatigue or severe exhaustion
Nausea, Vomiting or Diarrhea
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1 of 9
31
Do you have any of the following medical conditions? * This field is required.(Please select all that apply)
Yes
No
Heart Disease
Lung Disease
Kidney Disease
Diabetes
Chemotherapy, HIV or other immune disorders such as lupus or rheumatoid arthritis
Long-term use of prednisone or other immunosuppressive medications
Organ transplantation or absence of a spleen
Pregnancy
Heart Disease
Lung Disease
Kidney Disease
Diabetes
Chemotherapy, HIV or other immune disorders such as lupus or rheumatoid arthritis
Long-term use of prednisone or other immunosuppressive medications
Organ transplantation or absence of a spleen
Pregnancy
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1 of 8
32
Heart Disease
33
Lung Disease
34
Kidney Disease
35
Diabetes
36
Chemotherapy, HIV or other immune disorders
37
Long-term use of prednisone or other immunosuppressive medications
38
Organ transplantation or absence of a spleen
39
Pregnancy
40
Unique ID
41
42
Form_End_DateTime
43
Patient's Signature* This field is required.
Clear
Should be Empty:

New Patient Assessment

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