COVID 19 Med Facility Report

COVID-19 High Risk Case Report
Revised 03.08.22
REQUIRED fields are bold font and followed by an asterick symbol (*)
First*
Middle
Last*
If Patient is less than 18 years old, Parent's Name
Parent's First name
Parent's Last Name
DOB*

MonthDayYear
Date
Age today*
Gender

MaleFemale
Phone number*
Msg phone
Primary Language*

EnglishSpanishOther
Interpreter needed?

NoYes
Primary Care Provider (PCP)*
Location
Physical Address*
City*
State*
Zip*
County*
PO Box
State
Zip
County
WA state resident?

NoYes
How many other people do they live with?*
Residence type?

Congregate setting (Long term care, Multi-generational household, Dormitory, etc)HomelessH2A VisaOther
Name of Employer / School*
Last date Attended

MonthDayYear
Date
Phone number of Employer / School
Supervisor's / Teacher's Name*
Positive COVID-19 test date*

MonthDayYear
Date
Received COVID-19 vaccine?*

NoYes
Received COVID-19 booster?

NoYes
Date Symptoms Started*

MonthDayYear
Date
Date Isolation Ended

MonthDayYear
Date
Signs / Symptoms*

No symptoms; AsymptomaticFeverChillsHeadacheMuscle aches or painSore throatCongestionCoughDyspnea (shortness of breath)NauseaVomitingDiarrheaAbdominal pain or crampsNew onset loss of taste / smellFatigueOther
Recent exposure to a person confirmed to have the COVID-19 / SARS-CoV-2?

No / UnknownIf Yes, please list name(s) below!
Date of recent exposure:

MonthDayYear
Date
Name / Relationship 1
Name / Relationship 2
Name / Relationship 3
Pre-existing Health Conditions*

NoneDiabetesHeart diseaseImmunocompromisedObesityRespiratory conditions (COPD, asthma, etc)SmokerPregnantOther
Authorization to Disclose COVID 19 Test Results to Second Party Verbal permission given to share COVID-19 results with anyone who answers the call to any of the phone number(s) provided on this form.

Authorization to Disclose: NoAuthorization to Disclose: Yes
Authorization to Disclose: Yes -- Details, if any:
Name of Healthcare provider or support personnel submitting this High Risk case report: *
Your Name
Name of Healthcare facility submitting this High Risk case report:
Date

MonthDayYear
Date
Should be Empty: