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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.

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

Fever Cough Shortness of breath Sore throat Fatigue None

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?

Diabetes Heart disease Asthma Chronic lung disease Cancer None

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

Spouse/partner Child Parent Sibling Other relative

Name

First Name

Last Name

Phone Number

Date of Birth

Name*

First Name

Last Name

Phone Number*

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

Date of Birth*

Age

Address*

Street Address

City

State / Province

ZIP / Postal Code

Sex*

Male Female

Race/Ethnicity (check as many as apply)

White Black/African American Hispanic/Latino Asian Native American Other

Insurance Holder Name

First Name

Last Name

Insurance Holder Date of Birth

Insurance Holder Address

Street Address

City

State / Province

ZIP / Postal Code

What insurance type do you have?

Private Medicare Medicaid Uninsured Other

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?

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