PATIENT QUESTIONNAIRE FOR COVID-19 ANTIBODY TESTING

Patient Name: __________________________________________________________________________

Permanent Address: _____________________________________________________________________
Age: ________ If < 18, we will need an adult guardian to sign the consent form.
Sex: ________

1. Did you have any interaction with a confirmed 2. If with symptoms, have you been in a place with
COVID-19 patient? YES or NO a known COVID-19 transmission 14 days before
▪ When (approximate date): / / you developed signs and symptoms? YES or NO
▪ Where (location, city): _____________ ▪ When (approximate date): / /
▪ Where (location, city): _____________
3. Did you have history of recent travel between the dates of November 2019 until March 2020? YES or NO
▪ When (approximate date/s): ___________________________________________________
▪ Where (location of city/cities): _________________________________________________
4. Did you have any history of the following 5. Do you have any history of the following:
symptoms between the dates of November 2019 (Please check any of the following)
until present? ❑ Hypertension
▪ Fever (YES or NO) ❑ Diabetes
▪ Sore throat / dry throat (YES or NO) ❑ Chronic Kidney Disease
▪ Diarrhea (YES or NO) ❑ Liver Disease
▪ Colds (YES or NO) ❑ Cancer
▪ Cough (YES or NO) ❑ Others:
▪ Difficulty of breathing (YES or NO) ____________________________________
❖ If yes, when did it begin (approximate date): ____________________________________
____________________ ____________________________________
6. Are you pregnant? YES or NO Last Menstrual Period ____________
7. Are you updated with any of the following vaccinations?
▪ Flu vaccine: (indicate date last administered) ______________________
▪ Pneumonia vaccine: (indicate date last administered) ______________________
8. What is your degree of exposure? (Please check which applies to you)
▪ How often do you leave your house?
❑ I do not leave the house
❑ I leave the house 1-2x a week
❑ I leave the house 3-5x a week
▪ Do you wear a mask when you leave your house?
❑ Not applicable – I do not leave the house
❑ I leave the house with a mask
❑ I leave the house with no mask
▪ Do you live with anyone who has been working as a front liner?
❑ I do not live with a front liner
❑ I live with a service professional (non-medical front liner) who regularly works during this ECQ
❑ I live with a medical professional
▪ Are you at risk due to close contact?
❑ I do not live in a neighborhood with known COVID-19 cases
❑ I live a neighborhood with known COVID-19 cases
❑ I live in a house with a known COVID-19 case
By signing below, I certify all information is true and correct to the best of my knowledge.

Signature of Patient Signature of Receiving Physician

Date: / / Date: / /