Covid-19 Risk Questionnaire

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COVID-19 Risk Questionnaire

If you are having symptoms or feel you are a candidate for COVID-19 testing, please fill out this quick questionnaire. We will review them as they come in DURING OFFICE HOURS and will respond with what we think is the most appropriate next step. If you have urgent concerns after-hours, please contact your physician directly by phone/text.

If you are having a life-threatening emergency, call 911 or go to the closest ER.

* Indicates required field

Name *

First

Last

Date of birth *

Who is your primary care physician? *

Email *

Phone number *

Race (required for KDHE reporting) *

Do you have insurance? If so, please BRING A COPY of your card with you at time of testing. *

Yes No

Ethnicity (required for KDHE reporting) *

Are you experiencing any of the following? *

Fever Chills/shakes Full-body aches Headache Fatigue/malaise Sore throat Runny nose Sinus congestion Ear stuffiness or pain Itchy eyes, ears and/or throat Cough Trouble breathing (cannot speak in a full sentence without taking a breath, cannot perform your usual activities without having to stop to take a breath, etc) Increased leg swelling Vomiting Diarrhea Burning pain when you urinate Change in taste or smell None of the above

Other *

How long have you had each of your symptoms? Which one started first? Second? If you've had a fever, please report the exact temperature you recorded. How have you been treating your symptoms? *

If applicable, WHERE have you traveled outside of the KC Metro area in the last 14 days? What were your dates of travel? *

Have you had prolonged contact (i.e. standing closer than 6 feet for more than 10 minutes) with someone who has had a positive COVID lab test? *

Yes No Other

Do you work in a high-risk setting or institution (i.e. do you work in daycare, nursing home, healthcare setting, correctional facility, shelter, school, with food preparation, etc.)? *

Yes No Other

If you do work in a high-risk setting, what is the name & location of the business at which you work? *

What else do you think we should know? *

Submit

2020 Holidays - Clinic CLOSED
New Year's Day - Jan 1
Memorial Day - May 25
Juneteenth - June 19th
Independence Day - July 3
Labor Day - September 7
Annual Staff Retreat - September 18
Thanksgiving - November 26-27
Christmas - December 24-25
New Year's Eve - December 31

7199 W 98th Terrace, Suite 110
Overland Park, KS 66212
Bldg #3 in Windmill Village
clinic: 913-948-7652
fax: 913-273-2474
hello@healthsuite110.com

Clinic Hours
Monday-Thursday 9am-5pm
Friday 9am - 12pm
After hours by arrangement

ABOUT US
Member resources
Blog
COVID-19 update
Contact us
Join now

​​COVID-19 Risk Questionnaire

COVID-19 Risk Questionnaire