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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?
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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

Aug 14, 2020

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Page 1: 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

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? YesIf 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?

Page 2: 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

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):