COVID 19 Med Facility Report

COVID-19 High Risk Case Report
Revised 03.08.22
REQUIRED fields are bold font and followed by an asterick symbol (*)
Patient's First name
Middle
Last name
If Patient is less than 18 years old, Parent's Name
Parent's First name
Parent's Last Name
DOB

MonthDayYear
Date
Age today
Gender
Phone number
Format: (000) 000-0000.
Msg phone
Format: (000) 000-0000.
Primary Language
Interpreter needed?
Primary Care Provider (PCP)
PCP Location
Patient's Physical Address
City
State
Zip
County
PO Box
State
Zip
County
WA state resident?
How many other people live at the same location?
How many other people live at the same location?
Residence type?

Other
Name of Employer / School
Phone number of Employer / School
Format: (000) 000-0000.
Supervisor's / Teacher's Name
Last date Attended

MonthDayYear
Date
Positive COVID-19 test date

MonthDayYear
Date
Received COVID-19 vaccine?
Received COVID-19 booster?
Date of last Booster, if applicable

MonthDayYear
Date
Date Symptoms Started

MonthDayYear
Date
Date Isolation Ended

MonthDayYear
Date
Signs / Symptoms

Other
Recent exposure to a person confirmed to have the COVID-19 / SARS-CoV-2?
Date of recent exposure:

MonthDayYear
Date
Name / Relationship 1
Name / Relationship 2
Name / Relationship 3
Pre-existing Health Conditions

Other
Authorization to Disclose COVID 19 Test Results to Second Party Verbal permission given to share COVID-19 results with anyone who answers the call to any of the phone number(s) provided on this form.
Authorization to Disclose: Yes -- Details, if any:
Name of Healthcare provider or support personnel submitting this High Risk case report:
Your Name
Name of Healthcare facility submitting this High Risk case report:
Should be Empty: