The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

G5dDd46JDESCpQh7iDmKHJHx8wtpV2rhr2NGZtFYd9zKoKhoaIyrWW73NY3fzQpfcgH4IhQfYSL9c8pMgQHcI3M3KwQujVcvdvLaf2faukVZga5qwVy5zENMjpXb

COVID Screening

Please complete on all patients with positive screening to send to the Arkansas Department of Health for tracking purposes.

Patient First Name.

Patient Middle Name

Patient Last Name

Suffix (Jr, 3rd, etc.)

Patient Date of Birth

M-D-Y

Street Address

City

State

Zip Code

Patient Phone Number

Patient email

Date of Screening

M-D-Y

Current temperature

History of Fever

Yes

reset

How high was the temperature?

Cough

Yes

reset

Shortness of breath

Yes

reset

Sore Throat

Yes

reset

New onset chills

Yes

reset

New onset muscle pain.

Yes

reset

New onset headache.

Yes

reset

New loss of taste or smell.

Yes

reset

International or Domestic travel in the last 2 weeks

Yes

reset

Please list all travel locations

Have you been in contact with a person that has COVID-19?

Yes

reset

Whom were you in contact with that has COVID-19?

Was the screen positive?

Are you a healthcare worker?

Yes

reset

Are you a public safety worker? (EMS, Fire, Police)

Yes

reset

Are you pregnant?

Yes

reset

Do you have a medical problem with your immune system other than seasonal allergies?

Yes

reset

Do you have any of the following?

cancer

solid organ transplant

take immunosuppressive drugs

hemodialysis

advanced HIV

Do you have a history of lung disease?

Yes

reset

Do you have history of cardiac disease?

Yes

reset

Are you the sole care giver for someone at risk?defined as someone > 65 or with chronic lung disease

Yes

reset

Do you live in any of the following?

dorm

fraternity

sorority

shelter

jail

prison

skilled nursing facility

assisted living facility

adult family home

What is your age?

Did you recommend the mobile triage clinic?

Yes

reset

Patient Disposition

Home

reset

Disposition comments. Document all here.

Please add any comments.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.