Princeton Medical Group COVID-19 Symptom and Exposure Assessment Form

Name* This field is required.

First Name

Last Name

Date of Birth* This field is required.

Date

Best Number to reach you* This field is required.

Please enter a valid phone number.

example@example.com

Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

Are you experiencing any of the symptoms listed that may be COVID-19 related?* This field is required.Fever or chills Shortness of breath or difficulty breathing Cough Fatigue New loss of taste or smell Congestion or runny nose Nausea or vomiting Diarrhea Nausea or vomiting Sore throat

YES

Select the symptoms you have?

Fever or chills

Shortness of breath or difficulty breathing

Cough

Fatigue

New loss of taste or smell

Congestion or runny nose

Nausea or vomiting

Diarrhea

Nausea or vomiting

Sore throat

Other

Do you recall being exposed to someone who tested positive for COVID-19 within the last 10 days?* This field is required.

At Home

At work

At a public indoor location

At a public outdoor location

Unknown

When is your most recent contact with a coworker who tested positive for COVID-19?

Date

Were you wearing Personal Protective Equipment when you were exposed?* This field is required.

YES

What personal protective equipment were you Wearing?Pick all items you were wearing.

Medical Grade surgical mask supplied by PMG

Surgical mask

Cloth mask

N95 respirator supplied by PMG

KN 95 supplied by PMG

N95 respirator

Kn95 mask

I was not wearing any Type of PPE

List all Co-workers you have come in contact with at work within the last 3 days

Separate names with comma

Have you been tested for COVID-19 as a result of the exposure or after developing symptoms?* This field is required.

YES

When did you take the test?

Date

What type of test did you get

RT_ PCR

RAPID TEST

Saliva PCR

Rapid Antigen Home test

What were the results of the COVID test?

Positive

Negative

The result is pending

Please submit Your COVID-19 testing or documentation herePlease make sure your name and date is visible

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Did you get a booster dose? * This field is required.

YESNO

Princeton Medical Group COVID-19 Symptom and Exposure Assessment Form