COVID-19 Medical History Form

Gather a patient's or member's medical background, lifestyle habits, and current symptoms ahead of a COVID-19-related visit or admission.

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Full Name*

First Name

Last Name

Birthdate

Phone Number*

Address

Street Address

City

State / Province

ZIP / Postal Code

What is your gender?*

Male Female Other

Check the conditions that apply to you or to any of your immediate relatives:*

Diabetes Heart disease Hypertension Asthma Cancer None

Check the symptoms you are currently experiencing:*

Fever Cough Shortness of breath Loss of taste or smell Fatigue None

Are you currently taking any medication?*

Yes No

Do you have any medication allergies?*

Yes No

Do you use or have a history of using tobacco?*

Do you use or have a history of using illegal drugs?*

How often do you consume alcohol?*

Never Occasionally Weekly Daily

In a few words, explain your current health condition:

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