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Arlington County / Arlington Free Clinic / VDH AMCC ... Arlington County / Arlington Free Clinic / VDH AMCC Testing Site Application Information and Screening Form PART 3 STAFF ONLY

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  • Arlington County / Arlington Free Clinic / VDH AMCC Testing Site

    Application Information and Screening Form

    PART 1 Residency

    Address: __________________________________________ Apt# _______ Arlington, VA _____________ (ZIP)

    Yes No

    (Ask if house or apt.)

    Do you have health insurance? (Private, Medicaid, Medicare, General Relief)?

    Do you have a Primary Care Provider (PCP) / medical home? Yes No

    Income # in Family: _________ (include spouse, children, other relatives in the home)

    Annual Household Income: __________________ (IF INCOME EXCEEDS THRESHOLD OF 60% OF AMI, ASK THESE 2 QUESTIONS)

    Yes No Do you receive assistance from the Arlington Department of Human Services (DHS)?

    Do you receive assistance from any Arlington organization? Yes No

    Demographics

    Name: ____________________________________ _______________________________ _______ Last Name(s) (2 Maximum) First Name (1 Maximum) M.I. (1 Max.)

    Date of Birth: ______________________ Language Spoken: ______________________ (Month/Day/Year)

    Phone number: ______________________________ Alternate Contact #: _____________________________

    Are you pregnant? (if applicable) Yes No

    Race:

    Ethnicity: _______________________ Country of Origin: __________________________

    No

    Do you suffer from or are currently being treated for any chronic conditions? Yes If yes, what?_____________________________________________________________

    Date of Screening: ________________________

    Screener: _____________________________________________________________________

    Gender:

    PATIENT MEDICAL HISTORY

    Date of Onset: _________________

    Signs/ Symptoms:

    Body Aches Chills Cough Diarrhea Fever Headache

    Productive Cough

    Respiratory

    Myalgia/Arthralgia

    Shortness of Breath

    Pneumonia

    Other:

    Recent Exposure (if applicable):

    Contact w/ COVID-19 Positive Person:

    Other (Explain):

    Asymptomatic

    Loss of Smell/Taste Nausea

    Rash Vomiting

    Date of Abatement: _________________

    How did you find out about the testing site?

  • Arlington County / Arlington Free Clinic / VDH AMCC Testing Site

    Application Information and Screening Form

    PART 3

    STAFF ONLY

    I acknowledge I have read the consent statement in its entirety to the applicant, and received oral authorization for VDH to conduct a COVID-19 test. The Applicant attested that the infor- mation provided is truthful to the best of their knowledge.

    Screener Name: ________________________________ Date: ________________________________

    Appointment scheduled in OneDrive Spreadsheet:

    Appointment Date: _______________________________

    Appointment Time: ______________________________

    PART 2 READ CONSENT STATEMENT ALOUD TO APPLICANT

    ENGLISH I hereby authorize the Physicians and Nurse Practitioners of the Virginia Department of Health (VDH) to perform a COVID-19 test. I understand that medical records will be retained for ten years after the date of the last visit, then destroyed in a manner that assures confidentiality throughout the process and in its results.

    Yes No Do you attest that all the information provided is true to the best of your knowledge?

    SPANISH Por la presente yo autorizo a los Médicos y Enfermeras Practicantes del Departamento de Salud de Virginia (VDH) a hacerme una prueba COVID-19. Entiendo que los registros médicos se conservarán durante 10 años después de la fecha de la última prueba, luego destruidos de una manera que asegura la confidencialidad durante todo el proceso y en los resultados.

    ¿Certifica que toda la información proporcionada es verdadera a lo mejor de su conocimiento? Sí No

    Applicant Name: _______________________________________________________________

    Notes:

    Appointment NOT Scheduled (Explain):

    Untitled

    Address: Apt: in Family: Date of Birth: Phone number: Alt: Ethnicity: Country of Origin: If yes what: Consent: Yes MI: Race: [Unknown] Gender: [Male] TestingSiteRef: [Unknown] ChronicConditions: Off Date of Screening: First Name: Screener: ApptDate: ApptTime: Language: [English] AHI: Asymptomatic: Off Cough: Off Diarrhea: Off Chills: Off BodyAches: Off Headache: Off Fever: Off Pneumonia: Off Nausea: Off Myalgia/Arhtralgia: Off Productive Cough: Off Loss of Taste/Smell: Off Rash: Off Respiratory: Off SoB: Off Contact w/ Positive: Off Other(explain): Off Vomiting: Off Othersym: Off Date of Onset: Date of Abatement: OthersymText: Exposure: Notes: ApptNotScheduled: Surname: CheckApptScheduled: Off CheckNotApptScheduled: Off Zip: DHS ASSTY: Off DHS ASSTN: Off ArlOrgY: Off ArlOrgN: Off PCPy: Off PCPn: Off HI_y: Off HI_n: Off PregN: Off PregY: Off

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