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VISIT
EVAL
REVAL
DISCHARGE
SOC
HHCCN
NOMNC
ABN
MISSED VISIT
Medical Record Number
Patient Name
Clinician Id
Clinician Name
Discipline
Date of Service
Time In
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Clinician No. :
CovidClinicianNo
Clinician Name. :
CovidClinicianName
1. Have you been in contact with anyone who has been tested for Covid 19 or had a positive Covid 19 test ?
Yes
No
2. Are you currently experiencing any Covid 19 symptoms ?
Yes
No
3. Have you experienced any Covid 19 symptoms in the last 14 days ?
Yes
No
I cerify that I do not have any symtoms of fever and my temperature measured today is less than 100 deg F while rendering services to patient/client.
