COVID Nursing/Physician Assessment
Section A. Symptom History
Onset of not feeling well
Travel Details (If Yes)
Contact With Someone (If Yes)
Section B. High Risk Factors
If Yes
If Yes
If Yes
Medical History (If Yes)
If Yes
Medication List (If Yes)
If Yes
Allergies to Medications (If Yes)
Section C. Social History
Onset of not feeling well
What type of work do you do?
Section D. Current Vitals
Are you able to provide any of your vitals at home?