COVID-19 Risk Assessment

COVID Risk Assessment

This survey is provided by St. John’s Riverside Hospital (SJRH). The purpose of this risk assessment survey is to help you to make decisions about seeking medical care. It is NOT intended for the diagnosis or treatment of any illness or disease including, but not limited to, the COVID-19 virus.

If you are experiencing a true medical emergency, call 9-1-1 or go to your nearest Emergency Room. If you have questions or concerns about the symptoms you may be experiencing, you should contact your medical provider

This survey is not intended to create a provider-patient relationship and will not be treated as such. By participating in this survey, you are agreeing to provide basic information that may help you make decisions about seeking medical care and scheduling an appointment. You also agree and understand that, once you provide your contact information, a representative of SJRH may contact you for scheduling purposes.

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* 1. Are you overweight?

Yes

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* 2. Do you have

Asthma

COPD or Emphysema

Sleep Apnea

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* 3. Do you have diabetes?

Yes

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* 4. Do you have a heart condition or high blood pressure?

Yes

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* 5. Do you have a weak immune system, i.e. cancer, lupus?

Yes

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* 6. Do you have kidney disease?

Yes

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* 7. Do you smoke?

Yes

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* 8. Are you physically inactive?

Yes

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* 9. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Question Title

* 10. Please share the following information, so we may contact you with your results.

Name

ZIP/Postal Code

Email Address

Phone Number

If you answered “YES” to any of the above questions, you may have an increased risk of complications arising from COVID-19 virus infection. If you are experiencing COVID-19-related symptoms or wish to schedule a visit with a healthcare provider, you may also call St. John’s Telehealth at 914-964-4429 from 9:00am-10:00 pm.

If you have additional questions or concerns regarding the COVID-19 virus, you may also call the St. John’s COVID-19 Hotline at 914-964-4480. This Hotline is for informational purposes only is NOT intended for the diagnosis or treatment of any illness or disease including, but not limited to, the COVID-19 virus.

If you wish to schedule a visit with a St. John’s physician for any medical need, please contact our outpatient practice at 914-207-0004. The practice is open Monday – Friday, 9:00 am – 5:00pm.