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COVID-19 Test Request Form

This COVID-19 test request form collects information about a patient and their symptoms to request testing. It requests the reporter's information, the patient's demographic and contact information, clinical information including symptoms and medical history, and details about any previous laboratory testing. Specimen collection date and type are also included to submit with the tested sample.

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96 views1 page

COVID-19 Test Request Form

This COVID-19 test request form collects information about a patient and their symptoms to request testing. It requests the reporter's information, the patient's demographic and contact information, clinical information including symptoms and medical history, and details about any previous laboratory testing. Specimen collection date and type are also included to submit with the tested sample.

Uploaded by

duckoduck
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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COVID-19 Test Request Form

Please complete one form for each patient that COVID-19 testing is requested for. Include form with specimen submission.
REPORTER INFORMATION
Today’s Date: ____________________________________ Hospital/Clinic: _______________________________

Clinician Name: __________________________________ Phone: ______________________________________

PATIENT INFORMATION

First Name: ______________________ Last Name: ____________________ Phone: _______________________

Address: ________________________________________________________ City: _________________________

Zip Code: _______________________ County: _______________________ State: ________________________

Date of Birth: ______/______/_______ Age: ____________ Years/Months Sex: ☐ Male ☐ Female

Additional information required for testing:


Does the patient work in a healthcare facility or congregate setting? (e.g., long-term care facility, shelter, prison, jail)
☐ YES ☐ NO Facility Name:_____________________________________
Employee Occupation:______________________________
Did the patient work while ill? ☐ YES ☐ NO

Does the patient live in a congregate setting? (e.g., long-term care facility, shelter, group home, prison, jail)
☐ YES ☐ NO Facility Name:_____________________________________

Does the patient receive dialysis? ☐ YES ☐ NO

Does the patient work in a dialysis facility? ☐ YES ☐ NO


CLINICAL INFORMATION
Date of symptom onset: ______/______/_______ Does the patient have underlying conditions?
Is patient hospitalized? ☐ Y ☐ N ☐ None ☐ Immunocompromised
Admit Date: ________/________/___________ ☐ Unknown ☐ Pregnant
Hospital Name: ____________________________ ☐ Diabetes ☐ Chronic Lung Disease
☐ Y ☐ N ICU Admission? ☐ Hypertension ☐ Chronic Liver Disease
☐ Y ☐ N Intubated? ☐ Cardiac Disease ☐ Chronic Kidney Disease
☐ Y ☐ N Deceased? ☐ Other:______________________________
☐ Y ☐ N Chest X-ray or CT?
☐ Y ☐ N ECMO
LABORATORY TESTING
☐ YES ☐ NO Has the patient been tested for influenza?
Result: ☐ Positive ☐ Negative
Test Type: ☐ Rapid Test ☐ PCR
☐ YES ☐ NO Has the patient been tested for any other viral respiratory illness?
Result: _________________________________________________
COVID 2019 TESTING
Which specimen types have been sent to Minnesota Department of Health for COVID-19 testing?
☐ NP ☐ OP ☐ Other:________________ Specimen Collection Date:___________________________

v.4.23.2020

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