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COVID-19 QUESTIONNAIRE
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Have you traveled anywhere outside of Texas within the last 2 weeks?
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Traveled to:
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Have you experienced any of the following symptoms within the last 14 days?
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Fever:
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Chills:
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Sore throat:
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Cough:
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Chest pain:
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Shortness of Breath:
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Headaches:
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Change in senses:
• • •
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Any gastrointestinal symptoms?
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Gastrointestinal symptoms:
• • •
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Have you been exposed to a COVID-19 positive patient?
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When were you exposed and to who?
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Have you been tested for COVID-19?
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Date of test and results:
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If you tested positive before, have you been retested and gotten a negative result?
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Name of facility, date of test, and result:
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Have you received a COVID-19 Vaccine?
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COVID VACCINE BRAND, DATE OF ADMINISTRATION, FACILITY
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History of Present Illness:
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History of Present IIlness
• • •
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History of Present Illness Comments
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Pain Severity
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Severity Comments
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PREVENTATIVE SCREENINGS
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Last Mammogram (Annually, 40 year old +)
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Last Vision Exam (DIABETICS, PREDIABETICS, HYPERTENSION)
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Colonoscopy (50 years old +)
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Annual Stool Occult (50 years old +)
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Bone Density (65 years old+)
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DM Foot Exam
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PSA (Annually, 50 years old +)
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Depression Screening (Annually)
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Pap Smear
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Annual Physical
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Medicare Wellness (Annually)
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HEPATITIS C TESTING (BIRTH YEAR 1945 - 1965)
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Post Inpatient Care Visit:
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Facility Name
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Date of discharge
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Date of Interactive contact
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Date of Face to Face Visit
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Complexity of Medical Decision
• • •
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Medications reviewed and reconciled
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Medication reconciliation discussed with the patient
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Medication reconciliation discussed with the caregiver
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