Free COVID-19 Testing

Patient Survey

Please fill Completely and Text or Email a copy (Back & Front) of your License or ID and Insurance Card (If Available). Text: 225.288.9589 Email: eugenehivwork@gmail.com

Question Title

1. Please list your Name, Date of Birth, Race, Gender, & Drivers License or ID Number.

Question Title

2. Please list your home address and best contact number.

Question Title

3. Please list any and all Medical & Psychiatric Diagnoses you have. Also, In the past 3 months, have you been diagnosed with of influenza, pneumonia, or upper respiratory infection? If yes, what?

Question Title

4. Please provide the name of your Primary Care Physician and Insurance provider if available.

Question Title

5. Please identify if you are the head of household and how many peope are in your household.

Question Title

6. Have you missed any days from work due to any flu-like illnesses in the last 14 days?

Question Title

7. Have you had fever, chills, shortness of breath, body aches, swelling or a cough in the past 14 days?

Yes

Question Title

8. If you selected YES for question 7, please list exactly what you experienced.

Question Title

9. Within the last 14 Days, have you come into close contact with a laboratory confirmed COVID-19 patient?

Yes

Question Title

10. Within the last 14 days, have you traveled outside of the city, state or country? If so, where?

Yes

Free COVID-19 Testing

Patient Survey

Question Title

* 1. Please list your Name, Date of Birth, Race, Gender, & Drivers License or ID Number.

Question Title

* 2. Please list your home address and best contact number.

Question Title

* 3. Please list any and all Medical & Psychiatric Diagnoses you have. Also, In the past 3 months, have you been diagnosed with of influenza, pneumonia, or upper respiratory infection? If yes, what?

Question Title

* 4. Please provide the name of your Primary Care Physician and Insurance provider if available.

Question Title

* 5. Please identify if you are the head of household and how many peope are in your household.

Question Title

* 6. Have you missed any days from work due to any flu-like illnesses in the last 14 days?

Question Title

* 7. Have you had fever, chills, shortness of breath, body aches, swelling or a cough in the past 14 days?

Question Title

* 8. If you selected YES for question 7, please list exactly what you experienced.

Question Title

* 9. Within the last 14 Days, have you come into close contact with a laboratory confirmed COVID-19 patient?

Question Title

* 10. Within the last 14 days, have you traveled outside of the city, state or country? If so, where?

1. Please list your Name, Date of Birth, Race, Gender, & Drivers License or ID Number.

2. Please list your home address and best contact number.

3. Please list any and all Medical & Psychiatric Diagnoses you have. Also, In the past 3 months, have you been diagnosed with of influenza, pneumonia, or upper respiratory infection? If yes, what?

4. Please provide the name of your Primary Care Physician and Insurance provider if available.

5. Please identify if you are the head of household and how many peope are in your household.

6. Have you missed any days from work due to any flu-like illnesses in the last 14 days?

7. Have you had fever, chills, shortness of breath, body aches, swelling or a cough in the past 14 days?

8. If you selected YES for question 7, please list exactly what you experienced.

9. Within the last 14 Days, have you come into close contact with a laboratory confirmed COVID-19 patient?

10. Within the last 14 days, have you traveled outside of the city, state or country? If so, where?