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COVID 19 Symptoms Assessment
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COVID 19 Symptoms Assessment
Submissions from this form will be reviewed by a healthcare professional from Marshall Family Practice before the end of the next business day.
PLEASE NOTE - If you are already a patient of Fitzgibbon Hospital or one of our affiliated clinics, your best resource for connecting with your primary care provider is the FitzChart Patient Portal.
Please click here to access your portal
. You can utilize the "Message my Provider" tool within the portal.
If you develop
emergency warning signs
for COVID-19 get
medical attention immediately
. Emergency warning signs include*:
Trouble breathing
Persistent pain or pressure in the chest
New confusion or inability to arouse
Bluish lips or face
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?
*
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?
NO
YES
Your Email Address
*
Who is your doctor/medical provider?
*
Your Symptoms
*
I am a healthcare professional
I am age 10-19
I am age 20-29
I am age 30-39
I am age 40-49
I am age 50-59
I am age 60-69
I am over the age of 70
I have a dry cough
I have a fever of greater than 100.5 Degrees
I have lost the sense of taste or smell
I have shortness of breath
In the last 14 days, I have been in close contact with a known or suspected COVID-19 infected individual
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
If you develop
emergency warning signs
for COVID-19 get
medical attention immediately
. Emergency warning signs include*:
Trouble breathing
Persistent pain or pressure in the chest
New confusion or inability to arouse
Bluish lips or face
