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
OK
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?
Yes
No
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?
Yes
No
10.
Within the last 14 days, have you traveled outside of the city, state or country? If so, where?
Yes
No
Current Progress,
0 of 10 answered