Patient Record

Date of Service

Last Name

First Name

DOB

Chief Complaint

Possible exposure to novel coronavirus (COVID-19) Confirmed exposure to novel coronavirus (COVID-19) Confirmed diagnosis of COVID-19 infection Other

If Other above, details here:

HISTORY OF PRESENT ILLNESS / REVIEW OF SYSTEMS

Is it possible you have had exposure to COVID-19?

YES NO

If possible, please give context: when, where, etc...?

Have you been tested prior?

YES NO

If YES to the question above, when was last test, results, and any other relevant details:

Do you wear a mask and feel it is helping limit community spread of COVID-19 infections?

Wears a mask, feels it is helping. Wears a mask, does not feel it is helping. Does not wear a mask but does feel wearing masks is helping. Does not wear a mask, does not feel it is helping.

Have you traveled recently?

YES NO

If YES to the question above:

Have you had to quarantine or been quarantining?

YES NO

Any symptoms?

YES NO

If NO to the question above, how are you feeling today?:

SYMPTOMS: CHECK ONE FOR EACH POSSIBLE SYMPTOM BELOW

Fever/Chills

ADMITS DENIES NOT REVIEWED

Fatigue

ADMITS DENIES NOT REVIEWED

Cough

ADMITS DENIES NOT REVIEWED

Shortness of Breath

ADMITS DENIES NOT REVIEWED

Congested/Runny Nose

ADMITS DENIES NOT REVIEWED

Sore Throat

ADMITS DENIES NOT REVIEWED

Headache

ADMITS DENIES NOT REVIEWED

Body Aches

ADMITS DENIES NOT REVIEWED

Nausea/Vomiting

ADMITS DENIES NOT REVIEWED

Diarrhea

ADMITS DENIES NOT REVIEWED

Loss of Taste/Smell

ADMITS DENIES NOT REVIEWED

Trouble Breathing

ADMITS DENIES NOT REVIEWED

Chest Pain/Pressure

ADMITS DENIES NOT REVIEWED

New Confusion

ADMITS DENIES NOT REVIEWED

Inability to Wake

ADMITS DENIES NOT REVIEWED

Bluish Lips or Face

ADMITS DENIES NOT REVIEWED

Other HPI & ROS Notes:

How was this patient evaluated during this clinical encounter?

TELEHEALTH (VIDEO + AUDIO for most/all of encounter) TELEPHONE (AUDIO ONLY for most/all of encounter) IN-PERSON (face-to-face)

Patient consents to video visit per CDC guidelines during COVID-19 pandemic.

YES NO

ROS: A complete ROS was performed and negative except as noted above.

YES NO

PAST MEDICAL / SOCIAL / FAMILY HISTORY

Asthma

ADMITS DENIES NOT REVIEWED

Diabetes

ADMITS DENIES NOT REVIEWED

Hypertension

ADMITS DENIES NOT REVIEWED

Heart Disease

ADMITS DENIES NOT REVIEWED

Liver Disease

ADMITS DENIES NOT REVIEWED

Immunocompromised

ADMITS DENIES NOT REVIEWED

Hypercholesterolemia

ADMITS DENIES NOT REVIEWED

Chronic Lung Dz

ADMITS DENIES NOT REVIEWED

Chronic Kidney Dz w/ Dialysis

ADMITS DENIES NOT REVIEWED

Other:

Medications

Allergies

Surgeries

Smoking

Alcohol

Family Hx

PHYSICAL EXAM

Due to COVID pandemic if suspicion of exposure is possible providers are required to only initiate contact during physical exam if absolutely medically necessary. Please perform the physical exam below and include commentary in section below. When possible record vitals.

Height (in.)

Weight (lbs.)

Temperature (°F)

Vital signs are as reported by the patient using devices designed for home/personal use.

YES NO

If NO to the statement above:

Gen: appears well, in no acute distress and not ill appearing