COVID Nursing/Physician Assessment

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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 or 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)

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)
Diagnosed with Heart Disease?
If Yes
Allergies to Medications (If Yes)

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 ?

Current Vitals

Are you able to provide any of your vitals at home ?
Do you have trouble breathing
Are you able to provide any of your vitals at home ?
Do you have trouble breathing