Name First Middle Last Address * City, State and Zip * Date of Birth * Social Security Number * Gender * Male Female Race * Phone Number * Email Address * Allergies * Franklin Primary Health Center Patient * Yes No Who is your Primary Care Provider? * Emergency Contact Person Name * First Middle Last Emergency Contact Phone Number * Insurance Information Insurance Name * Insurance Subscriber Name * First Middle Last Insurance Contract Number * Insurance Group Number * Insurace Effective Date * Testing Criteria and Questionnaire Some description about this section Dates of Symptom(s) Traveled to High Risk Area (location) Symptoms * Exposed to a Person Positve for COVID-19 Cough Sore Throat Fever above 100.4*F Shortness of Breath/Difficulty Diarrhea Chills Headache Muscle Aches Vomiting Abdominal Pain Back Pain None Other Symptoms/Complaints Significant Medical History Recent Surgery and/or Hospitalization High Risk/Emergency warning signs to seek medical attention Some description about this section Symptoms New onset of confusion or inability to arouse? Difficulty breathing or Shortness of breath Signs of Cyanosis -Nail beds or lips blueish color Pressure in the chest or persistent chest pain? Have you been tested for COVID-19? Yes No If yes, Date and Where Essential Workers: Individuals presenting for testing and showing any symptoms of ill-health or with known exposure to COVID-19 will be treated as a " potential exposure" and will be instructed to self-isolate (quarantine) until test results are received in 3-5 days. Individuals presenting for testing who are asymptomatic and have no known history of exposure will not be given a work excuse. They will be expected to return to work. We encourage the use of a face mask and hand washing at all times.
