OP Portal COVID-19 Testing Illness Survey

Please fill this form out only if your child is 5 or older AND you already have an appointment for a nurse to screen your child. If your child is asymptomatic and is fully vaccinated, there is no need to test for covid. Thank you.

Patient Name

Date of Birth

1. Has your child received a Covid vaccine?

Yes No

If yes, please let us know which vaccine your child has received (Pfizer, Moderna, Johnson & Johnson) along with the date it was administered.

Date:

2. Are you / your child currently ill?

Yes (complete questions 2 through 5) No (go to question 6)

3. When did your/your child’s illness begin?

Today Yesterday 2 days ago 3 days ago 4 days ago 5 days ago 6 days ago 1 week ago or longer

4. During this illness have you/your child had any of the following symptoms? (Check all that apply)

Fever greater than or equal to 100.4

New onset cough or worsening cough

Difficulty breathing

Loss of taste or smell

None of the Above

5. If there has been a fever, what is the maximum temperature recorded?

7. Have you/your child been exposed to another person with documented Covid19? (Exposure is defined as being less than 6 feet away for more than 15 minutes cumulative time to a person while he/she was ill or up to 3 days prior to his/her illness began, who has tested positive for Covid19)

Yes No Unsure

8. If you answered “Yes” to question 5, when were you/your child exposed to the person with documented Covid19?

Today Yesterday 2 days ago 3 days ago 4 days ago 5 days ago 6 days ago 1 week ago or longer

9. Do you need a Covid19 test that is required for surgery, camp, sports, school or other reason?

Yes No

If yes, for what reason?

10. Would you prefer to schedule a Doctor visit rather than a lab test only visit for this concern?

Yes No

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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