COVID-19 Contact Tracing Form Patient Information Question Title * 1. What date (mm/dd/yyyy) did you begin to have symptoms OR if you did not have symptoms, when and where did you get tested? Question Title * 2. Contact Information Name * Address * City/Town * State/Province ZIP/Postal Code * Email Address * Phone Number * Question Title * 3. Parent or Guardian Name (required if under 18) Demographic Information Question Title * 4. Sex at Birth Male Female Unknown Question Title * 5. Date of Birth (mm/dd/yyyy) Question Title * 6. Race (Check all that apply) White or Caucasian Black or African American Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Other (please specify) Question Title * 7. Hispanic Ethnicity Hispanic/Latino Non-Hispanic/Latino Unknown Question Title * 8. Arab Ethnicity Arab Non-Arab Unknown Question Title * 9. Employer and/or School Name Question Title * 10. Occupation and/or Grade in School Clinical Information Question Title * 11. At time of symptom onset (if no symptoms present use the date patient tested positive) were you in quarantine because of a possible COVID-19 exposure. Yes No Unknown Question Title * 12. Do you have or did you have any symptoms? Yes No Unknown Question Title * 13. Check all the symptoms you experienced. None Fever Chills Rigors Muscle Aches Runny Nose Sore Throat Cough (new onset or worsening of chronic) Shortness of Breath Nausea Vomiting Headaches Abdominal Pain Diarrhea (>/=3 loose/looser than normal stools/24 hour period) Fatigue/Lethargy/Weakness Congestion Encephalopathy/Encephalitis Wheezing Difficulty Breathing Chest Pain Loss of Taste Loss of Smell Evidence of Pneumonia Seizure If yes to fever, what was the highest temperature? Question Title * 14. If yes to pneumonia, did you have a confirmatory Chest X-ray or CAT Scan done? Positive Negative Not Done Unknown Question Title * 15. Did your symptoms resolve? Yes No Unknown Pre-Existing Conditions Question Title * 16. Which of the following pre-existing conditions have you been diagnosed with? Check all that apply. None Chronic Liver Disease Hypertension Autoimmune Condition Chronic Lung Disease/COPD/Emphysema Neurologic Disease Cancer Chronic Renal Disease Severe Obesity (BMI>/=40) Cardio Vascular Disease Diabetes Mellitus Asthma/Reactive Airway Disease Other Chronic Disease, immunosuppressive Disease (please specify) Question Title * 17. Do you have a psychological/psychiatric condition? Yes No Question Title * 18. Do you have a disability (neurologic, neurodevelopmental, intellectual, physical, vision or hearing impairment? Yes No If yes, please specify Next
