Features
Dr. Stephen J. Sims |
Mountain View
Schedule COVID-19 Test
***WE ONLY TEST PATIENTS SHOWING SYMPTOMS***
Personal Details
First Name
Last Name
Date of Birth
Age
Gender
Male
Female
Cell Phone
Home Phone
Email Address
1/7
Address
Street
City
State
Zip Code
2/7
Insurance
(please fill out if INSURANCE HAS CHANGED)
Insurance Provider
Plan Type (PPO, HMO etc.)
Health Plan
Select one...
Individual
Employer
Name of Insured
Date of Birth of Insured
Policy ID Number
Group Number
From the back of your insurance card, please enter the following information:
Company name to mail claims to
P.O. Box Number
3/7
Symptoms
Cough?
Select one...
Yes
No
How many days?
Cough type (check all that apply)
Chest Burning
Wet Cough
Dry Cough
Note: If you're experiencing shortness of breath, please count your breaths per minute. If this number is more than 25, please go to the emergency room immediately!
Is your cough getting better or worse?
Select one...
Better
Worse
Unchanged recently
Shortness of Breath?
Select one...
Yes
No
4/7
Symptoms
Fever
Fever during this illness?
Select one...
Yes
No
If yes, what was your highest temperature?
Other Symptoms (check all that apply)
Rash
Diarrhea
Vomiting
Shaking chills
Sweats
Sore Throat
Onset within the first day, of severe fatigue
New yellow, green, or bitter cloudy nose mucus
Significant muscle aches in thighs, arms, or back
New significant loss of smell or taste
Nausea
Headache
Dizziness
Abdominal Pain
Much lower amount of urine than usual
5/7
Risk Analysis
Please answer these questions to help evaluate your risk level
Have you been in contact, within 6 feet, for more than 15min, with a COVID positive patient?
Select one...
Yes
No
Are you immunosuppressed due to medical treatment or a disease such as untreated HIV?
Select one...
Yes
No
Do you have contact with a person at high risk of severe COVID?
Select one...
Yes
No
What was the first full day of symptoms?
6/7
Health Issues
Please check any disease(s) you currently have or have suffered from in the past.
Asthma
Lung Disease from smoking
Other Lung Disease
Heart Disease
Stroke
High Blood Pressure
Diabetes
Kidney Disease
Being overweight with a BMI of 27+
Depression or anxiety requiring daily medication
None listed above
Other high risk condition
Certain medications need to be adjusted if you take Paxlovid for COVID illness. Please list your daily prescription medications here
by name only
, without the strength or frequency.
How did you hear about us?
Select one...
Email
Friend/Family
Facebook
Google
Dr. Sims
Doctor Referral
Other
* Required
Submitting this form means you agree with our
Terms of Service
&
Privacy Policy
7/7
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Thanks! I have received your form submission, I'll get back to you shortly!
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Drive Thru Coronavirus Testing
By Dr. Stephen Sims of Cogent Family Healthcare in Mountain View.
***WE ONLY TEST PATIENTS SHOWING SYMPTOMS***
Personal Details
First Name
Last Name
Date of Birth
Age
Gender
Male
Female
Cell Phone
Home Phone
Email Address
1/7
Address
Street
City
State
Zip Code
2/7
Insurance
Insurance Provider
Plan Type (PPO, HMO etc.)
Health Plan
Select one...
Individual
Employer
Name of Insured
Date of Birth of Insured
Policy ID Number
Group Number
From the back of your insurance card, please enter the following information:
Company name to mail claims to
P.O. Box Number
3/7
Symptoms
Cough?
Select one...
Yes
No
How many days?
Cough type (check all that apply)
Chest Burning
Wet Cough
Dry Cough
Note: If you're experiencing shortness of breath, please count your breaths per minute. If this number is more than 25, please go to the emergency room immediately!
Is your cough getting better or worse?
Select one...
Better
Worse
No Cough
Shortness of Breath?
Select one...
Yes
No
4/7
Symptoms
Fever
Fever during this illness?
Select one...
Yes
No
If yes, what was your highest temperature?
Other Symptoms (check all that apply)
Shaking chills
Sweats
Sore Throat
Onset within the first day, of severe fatigue
New yellow, green, or bitter cloudy nose mucus
Significant muscle aches in thighs, arms, or back
New significant loss of smell or taste
Nausea
Headache
Dizziness
Abdominal Pain
Much lower amount of urine than usual
5/7
Risk Analysis
Please answer these questions to help evaluate your risk level
Have you been in contact, within 6 feet, for more than 15min, with a COVID positive patient?
Select one...
Yes
No
Are you immunosuppressed due to medical treatment or a disease such as untreated HIV?
Select one...
Yes
No
Do you have contact with a person at high risk of severe COVID?
Select one...
Yes
No
What was the first full day of symptoms?
6/7
Health Issues
Please check any disease(s) you currently have or have suffered from in the past.
Asthma
Lung Disease from smoking
Other Lung Disease
Heart Disease
Stroke
High Blood Pressure
Diabetes
Kidney Disease
Being overweight with a BMI of 27+
Depression or anxiety requiring daily medication
None listed above
Other high risk condition
Certain medications need to be adjusted if you take Paxlovid for COVID illness. Please list your daily prescription medications here
by name only
, without the strength or frequency.
How did you hear about us?
Select one...
Email
Friend/Family
Facebook
Google
Dr. Sims
Doctor Referral
Other
* Required
Submitting this form means you agree with our
Terms of Service
&
Privacy Policy
7/7
← Back
Next
Thanks! I have received your form submission, I'll get back to you shortly!
Oops! Something went wrong while submitting the form
