Covid Form - Child

COVID- 19 Testing Questionnaire - Child
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Cell Phone*
Email Address*
example@example.com
Zip Code*
Do we have your permission to text your results?*

YesNo
Please answer the following questions. If the questions are unclear, please ask your healthcare provider.
1a. Has your child been exposed to anyone who tested positive for COVID-19 OR is waiting for test results?*

YesNoUnsure
1b. If yes, how many days ago was the last exposure to that person?
2a. Does or did your child have any of the following symptoms?

Fever or ChillsCoughShortness of breath/ difficulty breathingFatigueSore throatCongestion or runny noseMuscle of body achesDiarrheaHeadacheNausea or vomitingNew loss of taste of smell
2b. If yes, when did they first start?

MonthDayYear
Date
3a. Does your child attend school ?*

YesNo
3b. Which school do they attend?
3c. Which grade?
4. Is your child fully vaccinated for COVID-19?*

YesNo
5a. Has your child tested positive for COVID-19 in the last 90 days?*

YesNo
5b. If yes, what is the date of the positive test?

MonthDayYear
Date
6. Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknownDecline to Answer
7. Race*

American Indian/Alaskan NativeAsianBlack/African AmericanBlack/TrinidadianNative Hawaiian/Pacific IslanderWhiteUnknownOtherDecline to Answer
I understand that if my insurance is different from that of my child, I must provide my personal insurance. I understand that if my insurance does not cover the cost of the COVID-19 test, that I am responsible for any balance. If I am a WSD staff member, I understand that it is my responsibility to forward any balance to the WSD Human Resources Department otherwise I will be held responsible for the charges. I understand that COVID-19 is a reportable disease such that testing information including name and results will be forwarded to my local health department and possibly my school/district nurse. I authorize the staff at Tosa Pediatrics to leave a voicemail or text at the number above with any test results.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

COVID- 19 Testing Questionnaire - Child

Please answer the following questions. If the questions are unclear, please ask your healthcare provider.