Covid-19 Symptoms Assessment | Fitzgibbon Hospital

If you develop emergency warning signs for COVID-19 get medical attention immediately. Emergency warning signs include*:

Your Name*

Your Address including City, State, Zipcode*

Your Phone Number*

Last 4 of your Social Security Number*

Do you have a computer or smartphone device that would make it possible to do a video visit with a medical provider to discuss your symptoms?*

Your Email Address*

Who is your doctor/medical provider?*

Your Symptoms*

I have one or more of the following conditions (Please check all that apply)*

Cancer - whether currently undergoing treatment or in remission

Diabetes

Heart Disease including high blood pressure

I am pregnant

I have an autoimmune disease such as Rheumatoid Arthritis, HIV, Lupus

I have had prolongued use of Prednisone

Kidney Disease

Lung Disease including asthma, emphysema