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

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

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

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* 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?

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

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

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

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

Yes

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

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

Yes

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

Yes