COVID Nursing/Physician Assessment

Section A. Symptom History

Onset of not feeling well
Do you have trouble breathing?
Do you have any discharge from your eyes
Have you travelled in the last 14 days
Do you have a cough
Do you have a runny nose
Do you have any abdominal symptoms like nausea, vomiting, diarrhea
Have you been in close contact with someone diagnosed with COVID 19
Do you have a fever greater than 38 degrees
Do you have a sore throat
Are you feeling severe fatigue or extreme muscle aches
Travel Details (If Yes)
Contact With Someone (If Yes)

Section B. High Risk Factors

Do you have trouble breathing?
If Yes
Have you recently had surgery?
If Yes
Have you recently been hospitalized?
Recently had treatment for cancer?
If Yes
Medical History (If Yes)
Have you been diagnosed with Diabetes?
If Yes
Medication List (If Yes)
Have you been diagnosed with Heart Disease?
If Yes
Allergies to Medications (If Yes)

Section C. Social History

Onset of not feeling well
What type of work do you do?
Are there any family members in your home that are over 70?

Section D. Current Vitals

Are you able to provide any of your vitals at home?

Section E. Clinical Use

Do you have trouble breathing?
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