COVID-19 Screening Form Template

Easily send and receive your COVID-19 Screening Form Template online. Send patients your screening form to fill out on their phone, tablet, or computer. Patients securely sign and submit completed forms directly to your account. Track the progress of COVID-19 screening forms, send automated reminders, and receive completed screening forms online.

COVID-19 Screening Form Template

COVID-19 Screening Form Template

Give patients the ability to complete your COVID-19 screener form online. Securely review your patient's symptoms form online before they step foot into your office. Help reduce the spread of COVID-19 with a secure online form.

Setup a COVID-19 screener form for free

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What You Should Know About COVID-19

All information referenced here is from the Center for Disease Control and Prevention

The best way to prevent illness is to avoid being exposed to this virus.

The virus is thought to spread mainly from person-to-person.

  • Between people who are in close contact with one another (within about 6 feet).
  • Through respiratory droplets produced when an infected person coughs or sneezes.

These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.

Spread from contact with infected surfaces or objects

It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.

Can someone spread the virus without being sick?
  • People are thought to be most contagious when they are most symptomatic (the sickest).
  • Some spread might be possible before people show symptoms; there have been reports of this occurring with this new coronavirus, but this is not thought to be the main way the virus spreads.
How easily does the virus spread?

How easily a virus spreads from person-to-person can vary. Some viruses are highly contagious (spread easily), like measles, while other viruses do not spread as easily. Another factor is whether the spread is sustained. The virus that causes COVID-19 seems to be spreading easily and sustainably in the community (“community spread”) in some affected geographic areas. Community spread means people have been infected with the virus in an area, including some who are not sure how or where they became infected.

Symptoms

For confirmed coronavirus disease 2019 (COVID-19) cases, reported illnesses have ranged from mild symptoms to severe illness and death. Symptoms can include:

  • Fever
  • Cough
  • Shortness of breath

CDC always recommends everyday preventive actions to help prevent the spread of respiratory diseases, including:

  • Avoid close contact with people who are sick.
  • Avoid touching your eyes, nose, and mouth.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
  • Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
  • Follow CDC’s recommendations for using a facemask.
    • CDC does not recommend that people who are well wear a facemask to protect themselves from respiratory diseases, including COVID-19.
    • Facemasks should be used by people who show symptoms of COVID-19 to help prevent the spread of the disease to  others. The use of facemasks is also crucial for health workers and people who are taking care of someone in close settings (at home or in a health care facility).
  • Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing.
    • If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty.
Steps to help prevent the spread of COVID-19 if you are sick

If you are sick with COVID-19 or suspect you are infected with the virus that causes COVID-19, follow the steps below to help prevent the disease from spreading to people in your home and community.

 
Stay home except to get medical care
You should restrict activities outside your home, except for getting medical care. Do not go to work, school, or public areas. Avoid using public transportation, ride-sharing, or taxis.
 
Separate yourself from other people and animals in your home
People: As much as possible, you should stay in a specific room and away from other people in your home. Also, you should use a separate bathroom, if available. Animals: You should restrict contact with pets and other animals while you are sick with COVID-19, just like you would around other people. Although there have not been reports of pets or other animals becoming sick with COVID-19, it is still recommended that people sick with COVID-19 limit contact with animals until more information is known about the virus. When possible, have another member of your household care for your animals while you are sick. If you are sick with COVID-19, avoid contact with your pet, including petting, snuggling, being kissed or licked, and sharing food. If you must care for your pet or be around animals while you are sick, wash your hands before and after you interact with pets and wear a facemask. See COVID-19 and Animals for more information.
 
Call ahead before visiting your doctor
If you have a medical appointment, call the healthcare provider and tell them that you have or may have COVID-19. This will help the healthcare provider’s office take steps to keep other people from getting infected or exposed.
 
Wear a facemask
You should wear a facemask when you are around other people (e.g., sharing a room or vehicle) or pets and before you enter a healthcare provider’s office. If you are not able to wear a facemask (for example, because it causes trouble breathing), then people who live with you should not stay in the same room with you, or they should wear a facemask if they enter your room.
 
Cover your coughs and sneezes
Cover your mouth and nose with a tissue when you cough or sneeze. Throw used tissues in a lined trash can; immediately wash your hands with soap and water for at least 20 seconds or clean your hands with an alcohol-based hand sanitizer that contains 60 to 95% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Soap and water should be used preferentially if hands are visibly dirty.
 
Clean your hands often
Wash your hands often with soap and water for at least 20 seconds or clean your hands with an alcohol-based hand sanitizer that contains 60 to 95% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Soap and water should be used preferentially if hands are visibly dirty. Avoid touching your eyes, nose, and mouth with unwashed hands.
 
Avoid sharing personal household items
You should not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. After using these items, they should be washed thoroughly with soap and water.
 
Clean all “high-touch” surfaces everyday
High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Also, clean any surfaces that may have blood, stool, or body fluids on them. Use a household cleaning spray or wipe, according to the label instructions. Labels contain instructions for safe and effective use of the cleaning product including precautions you should take when applying the product, such as wearing gloves and making sure you have good ventilation during use of the product.
 
Monitor your symptoms
Seek prompt medical attention if your illness is worsening (e.g., difficulty breathing). Before seeking care, call your healthcare provider and tell them that you have, or are being evaluated for, COVID-19. Put on a facemask before you enter the facility. These steps will help the healthcare provider’s office to keep other people in the office or waiting room from getting infected or exposed. Ask your healthcare provider to call the local or state health department. Persons who are placed under active monitoring or facilitated self-monitoring should follow instructions provided by their local health department or occupational health professionals, as appropriate. If you have a medical emergency and need to call 911, notify the dispatch personnel that you have, or are being evaluated for COVID-19. If possible, put on a facemask before emergency medical services arrive.
 
Discontinuing home isolation
Patients with confirmed COVID-19 should remain under home isolation precautions until the risk of secondary transmission to others is thought to be low. The decision to discontinue home isolation precautions should be made on a case-by-case basis, in consultation with healthcare providers and state and local health departments.
 

COVID-19 Screener Form Template Features

Setup your COVID-19 screener forms online and streamline your process of collecting screener forms from patients.
Required HIPAA Compliant Online Form Fields
Required Form Fields

Always get the information you need with required fields. Patients can only submit COVID-19 related forms when they complete all of your required fields. Never receive an incomplete screener form again.

Required Form Fields »

HIPAA Compliant Electronic Signature
Electronic Signatures

Collect electronic patient signatures before the appointment. Easily give your patients the ability to digitally sign COVID-19 screener forms with their phone, tablet, or computer.

Electronic Signatures »

Card Photo Uploads

Have your patient take a picture of their insurance and ID cards. New patients will automatically upload a photo of their card information, so you can verify it before the appointment.

Card Photo Uploads »

Form Autocomplete

Have your patient enter information once and have it autocomplete throughout your COVID-19 screener form online. Automatically populate PHI directly into additional fields and screener forms.

Form Autocomplete »

HIPAA Compliant Online Form Submission
Online Form Submissions

Patients sign and submit forms securely to your online account. Review and manage completed COVID-19 screener forms before the appointment.

Online Form Submissions »

HIPAA Compliant Conditional Logic Forms
Conditional Logic Forms

Only show information that is relevant to the patient with conditional logic screener forms. Make it simple for your patients to complete your COVID-19 screener forms and improve the accuracy of the data you receive with conditional logic.

Conditional Logic Forms »

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  • Are having patients fill out paper forms during the appointment
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  • Are spending time manually printing and scanning paper forms

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