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?