Arlington County / Arlington Free Clinic / VDH AMCC …...Arlington County / Arlington Free Clinic /...
Transcript of Arlington County / Arlington Free Clinic / VDH AMCC …...Arlington County / Arlington Free Clinic /...
Arlington County / Arlington Free Clinic / VDH AMCC Testing Site
Application Information and Screening Form
PART 1 Residency
Address: __________________________________________ Apt# _______ Arlington, VA _____________ (ZIP)
Yes No
(Ask if house or apt.)
Do you have health insurance? (Private, Medicaid, Medicare, General Relief)?
Do you have a Primary Care Provider (PCP) / medical home? Yes No
Income # in Family: _________ (include spouse, children, other relatives in the home)
Annual Household Income: __________________ (IF INCOME EXCEEDS THRESHOLD OF 60% OF AMI, ASK THESE 2 QUESTIONS)
Yes No Do you receive assistance from the Arlington Department of Human Services (DHS)?
Do you receive assistance from any Arlington organization? Yes No
Demographics
Name: ____________________________________ _______________________________ _______
Last Name(s) (2 Maximum) First Name (1 Maximum) M.I. (1 Max.)
Date of Birth: ______________________ Language Spoken: ______________________ (Month/Day/Year)
Phone number: ______________________________ Alternate Contact #: _____________________________
Are you pregnant? (if applicable) Yes No
Race:
Ethnicity: _______________________ Country of Origin: __________________________
No
Do you suffer from or are currently being treated for any chronic conditions? YesIf yes, what?_____________________________________________________________
Date of Screening: ________________________
Screener: _____________________________________________________________________
Gender:
PATIENT MEDICAL HISTORY
Date of Onset: _________________
Signs/Symptoms:
Body Aches Chills Cough Diarrhea Fever Headache
Productive Cough
Respiratory
Myalgia/Arthralgia
Shortness of Breath
Pneumonia
Other:
Recent Exposure (if applicable):
Contact w/ COVID-19 Positive Person:
Other (Explain):
Asymptomatic
Loss of Smell/Taste Nausea
Rash Vomiting
Date of Abatement: _________________
How did you find out about the testing site?
Arlington County / Arlington Free Clinic / VDH AMCC Testing Site
Application Information and Screening Form
PART 3
STAFF ONLY
I acknowledge I have read the consent statement in its entirety to the applicant, and received oral authorization for VDH to conduct a COVID-19 test. The Applicant attested that the infor-mation provided is truthful to the best of their knowledge.
Screener Name: ________________________________ Date: ________________________________
Appointment scheduled in OneDrive Spreadsheet:
Appointment Date: _______________________________
Appointment Time: ______________________________
PART 2 READ CONSENT STATEMENT ALOUD TO APPLICANT
ENGLISH I hereby authorize the Physicians and Nurse Practitioners of the Virginia Department of Health (VDH) to perform a COVID-19 test. I understand that medical records will be retained for ten years after the date of the last visit, then destroyed in a manner that assures confidentiality throughout the process and in its results.
Yes No Do you attest that all the information provided is true to the best of your knowledge?
SPANISH Por la presente yo autorizo a los Médicos y Enfermeras Practicantes del Departamento de Salud de Virginia (VDH) a hacerme una prueba COVID-19. Entiendo que los registros médicos se conservarán durante 10 años después de la fecha de la última prueba, luego destruidos de una manera que asegura la confidencialidad durante todo el proceso y en los resultados.
¿Certifica que toda la información proporcionada es verdadera a lo mejor de su conocimiento? Sí No
Applicant Name: _______________________________________________________________
Notes:
Appointment NOT Scheduled (Explain):