Welcome to FHCCGLA COVID-19 Electronic Patient Form Demographic InformationPatient's Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient DOB* Date Format: MM slash DD slash YYYY Patient SSNPatient Contact Number*Ethnicity*Gender*Patient Email Address* Monthly Income*Family Size*Preferred Language*Upload photo of ID (if possible)Covid-19: Questionnaire1. Are you experiencing Covid-19 symptoms, such as:* Loss of taste or smell Cough Shortness of breath or difficulty breathing Fevers (Temp > 100.4F or 38C) Chills/Rigors Diarrhea Vomiting/Nausea Muscle pain Headache Sore throat Runny Nose Confusion Other: (SPECIFY) None of the above Specify if other*2. When did your symptoms start? Date Format: MM slash DD slash YYYY Not Applicable 3. Are you 65 years of age or older?*a. Yesb. No4. Have you been in contact with anyone known to be COVID positive?*a. Yesb. NoApproximate date of exposure* Date Format: MM slash DD slash YYYY 5. Are you employed in one of the following categories?* First responders Critical government personnel Health care professionals Grocery workers Delivery, rideshare, taxi and public transit drivers Credentialed members of the media Construction workers School Other 6. Do you have any of the following chronic health conditions:* Asthma/chronic lung disease/ Smoke Diabetes Serious heart conditions Chronic kidney disease being treated with dialysis Severe obesity Pregnancy Compromised immune system (e.g., due to HIV/AIDS, cancer/chemotherapy, organ transplant, or on medications that suppress your immune system) None/ Unknown Other 7. Do you have Health insurance?*a. Yesb. NoWhat insurance company are you currently insured with?*8. Current living arrangement:*Home or apartment, Own or RentHomelessLong-term care facilityOther living arrangementPlease specify if other living arrangement*Consent* I consent to receive “negative” COVID results through email or text message. NOTE: If your test results are “positive” a FHCCGLA provider will call you for results. This iframe contains the logic required to handle Ajax powered Gravity Forms.