Language
English (UK)
Spanish (Latin America)
San Benito County Public Health Services
COVID-19 Rapid Test Report Form
Person Being Tested
*
First Name
Last Name
Phone
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex:
*
Male
Female
Non-Binary
Test date (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Exposure Date(Last date of close contact to a confirmed case):
-
Month
-
Day
Year
Date
Exposure Date Unknown
Unknown
Symptoms (check all that apply)
Fever (>100.4°F, 38°C)
Subjective fever (feverish)
Cough
Sore throat
Body aches
Abdominal pain
Diarrhea
Headache
Nausea
Vomiting
Body aches
Chills
Lethargy/fatigue
Loss of smell
Loss of taste
Runny nose
Shortness of breath
Difficulty breathing
Dermatologic Finding
Other
Symptom Start date:
-
Month
-
Day
Year
Date
No Symptoms
Chronic Conditions (Check all that apply)
Asthma
Cardiovascular Disease
Chronic Lung Disease
Stroke, DVT
Hypertension
Difficulty Diabetes
Chronic Kidney Disease
Neurological/Neuro-Developmental
Obesity
Chronic Liver Disease
Immunocompromised
Cancer
Current Smoker
Former Smoker
Pregnant
None
Unknown
Other
Primary Language (check one)
English
Spanish
Other
Ethnicity (check one)
Hispanic/Latino
Non-Hispanic/Non-Latino
Unknown
Race (check one)
African-American/Black
American Indian/Alaska Native
Asian
Pacific Islander
White
Unknown
Other
Vaccination History
Has person received COVID-19 Vaccine?
*
Yes
No
Unknown
Dose #1 Date:
-
Month
-
Day
Year
If unknown leave blank
Dose #1 Type:
Moderna
Pfizer
Other
Unknown
Dose #2 Date:
-
Month
-
Day
Year
If unknown leave blank
Dose #2 Type:
Moderna
Pfizer
Unknown
Other
Dose #3 Date:
-
Month
-
Day
Year
If unknown leave blank
Dose #3 Type:
Moderna
Pfizer
Unknown
Other
Test Type
Abbott BinaxNOW
BD Veritor
Quidel Sofia
Other
Unknown
TEST RESULT
Negative
Positive
Indeterminate
Not Tested
Employer/Agency
Name of Person Completing Form:
First Name
Last Name
Phone Number of Person Completing Form
Submit
Should be Empty: