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  • PatientRegistration COVID19Tes 2020-05!14!1036

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    Nidia Lohaiza
    9 views5 pages
    The document is a patient registration form requesting basic contact and health information. It requests the patient's name, address, date of birth, phone number, email, gender, ethnicity, race, symptoms, date symptoms began, and relevant health information. The form notes that a phone number is needed to contact the patient with test results.

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    The document is a patient registration form requesting basic contact and health information. It requests the patient's name, address, date of birth, phone number, email, gender, ethnicity, race, symptoms, date symptoms began, and relevant health information. The form notes that a phone number is needed to contact the patient with test results.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    9 views5 pages

    PatientRegistration COVID19Tes 2020-05!14!1036

    Uploaded by

    Nidia Lohaiza
    The document is a patient registration form requesting basic contact and health information. It requests the patient's name, address, date of birth, phone number, email, gender, ethnicity, race, symptoms, date symptoms began, and relevant health information. The form notes that a phone number is needed to contact the patient with test results.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 5

    Page 1

    Patient Registration

    Please complete the form below. You must enter a name, address, date of birth, and phone number. We need a
    phone number to contact you with results.

    Response was added on 05/14/2020 10:18am.

    Select the city where this test is occurring North Platte


    McCook
    Kearney
    Hastings
    Wayne
    Dakota City
    Grand Island
    Fremont
    Ord
    Springfield/Papillion
    York
    Lexington
    Crete
    Tecumseh
    Schuyler
    Norfolk
    Cozad
    Gibbon
    Omaha
    Beatrice
    Columbus
    Holdrege
    West Point
    Shelby
    Ogallala
    St. Paul
    Sidney/Oshkosh
    Bridgeport/Alliance
    Chadron/Gordon
    Neligh
    Bellevue
    Nebraska City
    Valentine
    Humboldt
    Omaha - One World / Metro Community College South
    Fairbury
    Alma
    Franklin
    Other

    First Name Nidia

    Middle Name
    __________________________________

    Last Name Lohaiza

    Patient Street Address Galvin rd


    (If you do not have an address, use your employer
    address, local health department address, or
    other location )

    05/14/2020 10:36am projectredcap.org


    Page 2

    Patient City/Town Bellevue


    (If you do not have an address, use your employer
    address, local health department address, or
    other location )

    05/14/2020 10:36am projectredcap.org


    Page 3

    Patient State AL
    AK
    AZ
    AR
    CA
    CO
    CT
    DE
    DC
    FL
    GA
    HI
    ID
    IL
    IN
    IA
    KS
    KY
    LA
    ME
    MD
    MA
    MI
    MN
    MS
    MO
    MT
    NE
    NV
    NH
    NJ
    NM
    NY
    NC
    ND
    OH
    OK
    OR
    PA
    RI
    SC
    SD
    TN
    TX
    UT
    VT
    VA
    WA
    WV
    WI
    WY
    (If you do not have an address, use your employer
    address, local health department address, or
    other location )

    Patient Zip 68005


    (If you do not have an address, use your employer
    address, local health department address, or
    other location )

    05/14/2020 10:36am projectredcap.org


    Page 4

    Phone Number (to call for results) (402) 871-6330


    (If you do not have a phone number, enter any
    number we can call with results: family member,
    employer, local health departmet phone)

    Email address (if no phone number)


    __________________________________

    Date of Birth 11-26-1986

    Gender Male
    Female
    Other

    Ethnicity Hispanic or Latino


    Not Hispanic or Latino
    Unknown

    Race White or Caucasian


    Black or African American
    Asian or Asian American
    Native American
    Native Hawaiian or other Pacific Islander
    Other Race
    Unknown

    Symptoms Fever or chills


    Cough
    Shortness of breath, or trouble breathing
    Sore throat
    Runny nose
    Loss of taste
    Loss of smell
    Diarrhea
    Fatigue
    Congestion
    Other
    (Select all that apply, leave blank if
    asymptomatic)

    Date when first symptom started 05-12-2020


    (Choose the date when the first symptom appeared)

    Do any of these apply to you?


    (Select all that apply)

    Currently hospitalized
    Healthcare worker
    Public safety/First Responder (EMS, law enforcement, firefighter)
    Resident or staff at nursing home or long-term care facility
    Staff at group home, homeless shelter, or daycare
    Resident at group home, homeless shelter, or daycare facility
    Resident at group home (nursing home, homeless shelter, daycare)
    Staff at group home (nursing home, homeless shelter, daycare)
    Direct or close contact to a patient with COVID-19, within 14 days
    Individual >65 years old or patient with serious underlying conditions
    Travel outside of Nebraska within 14 days
    Other high risk setting: meat processing plant, large manufacturer, etc.

    05/14/2020 10:36am projectredcap.org


    Page 5

    Worksite or facility name


    __________________________________

    05/14/2020 10:36am projectredcap.org

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