COVID-19 (Coronavirus) Online Assessment

Submitted assessments will be reviewed by an advanced practice nurse or physician and you will be emailed next steps during clinic hours.

Patient Information

 
 

Sex


 
 

Symptoms & Additional Information

Do you currently have these symptoms?

Cough


 

Fever


 

Shortness of Breath


 

In the last 14 days, did you have close contact with a suspected or laboratory-confirmed COVID-19 (Coronavirus) patient?


 

Are you healthcare professional?


 

Are you over the age of 65?


 

Do you have any of the following medical conditions?

  • Heart disease
  • Lung disease
  • Kidney disease
  • Diabetes
  • Chemotherapy, HIV, or other immune disorders such as lupus, rheumatoid arthritis
  • Long term use of prednisone or other immunosuppressive medications
  • Organ transplantation or absence of spleen
  • Pregnancy

Select “Yes” if you have any of the listed medical conditions.