Blank Covid Test Form PDF – Overview
Blank Covid Test Form is filled for each patient that COVID-19 testing is requested for. Include form with specimen submission.
COVID-19 affects different people in different ways. Infected people have had a wide range of symptoms reported – from mild symptoms to severe illness.
Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:
- Fever or chills
- Cough
- Shortness of breath or difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
- Diarrhea
Look for emergency warning signs for COVID-19.
If someone is showing any of these signs, seek emergency medical care immediately:
- Trouble breathing
- Persistent pain or pressure in the chest
- New confusion
- Inability to wake or stay awake
- Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
Blank Covid Test Form
Here are the simple steps to fill the Blank Covid Test Form
REPORTER INFORMATION on Blank Covid Test Form
- Today’s Date
- Hospital/Clinic
- Clinician Name
- Phone
PATIENT INFORMATION on covid test form
- First Name
- Last Name
- Phone
- Address
- City
- Zip Code
- County
- State
- Date of Birth
- Age
- Sex
- 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)
Facility Name
Employee Occupation - Did the patient work while ill
- Does the patient live in a congregate setting? (e.g., long-term care facility, shelter, group home, prison, jail)
Facility Name
Does the patient receive dialysis
Does the patient work in a dialysis facility
CLINICAL INFORMATION on the form
- Date of symptom onset
- Is patient hospitalized
- Admit Date
- Hospital Name
- Does the patient have underlying conditions
LABORATORY TESTING details
- Has the patient been tested for influenza
- Has the patient been tested for any other viral respiratory illness
COVID 2019 TESTING
- Which specimen types have been sent to Minnesota Department of Health for COVID-19 testing
Download Blank Covid Test Form PDF from www.health.state.mn.us using the direct download link given below.