COVID-19 Test Prescreening - Pine Ridge Pharmacy

First Name *

Last Name *

Date *

Sex *

Race *

Ethnicity *

DOB *

Phone *

Email *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Do you have any of the following life-threatening symptoms: *

* Extremely difficult breathing (gasping for air or cannot talk without catching your breath)
* Blue-colored lips or face
* Severe and constant dizziness or lightheadedness
* Acting confused (new or worsening)
* Unconscious or very difficult to wake up
* Slurred speech (new or worsening)
* New seizure or seizures that won’t stop

Do you have any of the following symptoms: *

* Fever (above 100°F)
* Dry Cough
* Shortness of breath or difficulty breathing
* Chills or repeated shakes with chills
* Muscle pain
* Headache
* Sore throat
* Loss of taste or smell

Have you been exposed to someone who has COVID-19? Exposed means you were within 6 feet of the person for over ten minutes. *

Do you require testing for school, travel, your job, or do you believe that you need to be tested for some other reason? *

Have you traveled internationally, attended large public gatherings or been in close proximity with many people? *

Do you live, work or volunteer in a care facility such as a nursing or group home? *

How would you like to receive your test results? *

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