COVID-19 Symptoms Self-Report Form

Used by medical offices to collect a detailed report of a patient's symptoms, pre-existing conditions, contact details, and insurance information.

Use this template

What symptoms are being experienced right now? (check as many as apply)

How severe are these symptoms? (1 = mild and 10 = severe)

Do you (the patient) have a history of any of the following pre-existing medical conditions?

Are you immunocompromised?

Yes No Not sure

On or about what date did symptoms begin?

Are you reporting symptoms for yourself or someone else in your household?

Myself Someone else

Relationship to Person with Symptoms

Name

Nombre

Apellido

Phone Number

Date of Birth

Name

Nombre

Apellido

Phone Number

Emergency Contact Name

Nombre

Apellido

Emergency Contact Phone Number

Date of Birth

Age

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Sex

Male Female

Race/Ethnicity (check as many as apply)

Insurance Holder Name

Nombre

Apellido

Insurance Holder Date of Birth

Insurance Holder Address

Dirección

Ciudad

Estado / Provincia

Código postal

What insurance type do you have?

What is your insurance policy number?

Please upload a picture of your insurance card (front and back).

Max 10 MB per file

Would you like someone to contact you about these symptoms?

Yes No

Is there anything else we should know about these symptoms or your situation?

COVID-19 Symptoms Self-Report Form

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