Covid 19 Traveler Companion
COVID-19 Traveler Companion Information
Patient First Name
Patient Last Name
Companion Full Name
*
Age
Relation to the Patient
*
1
Does the patient who will be traveling for procedure present any of the following symptoms currently or during the last 15 days?
Fever
*
Yes
No
Cough
*
Yes
No
Shortness of breath
*
Yes
No
Respiratory illnesses
*
Yes
No
Has the patient traveled outside the United States during the last 6 months?
*
Yes
No
Where did you travel?
Where did you travel?
Where did you travel?
Date of Travel
Date of Travel
Date of Travel
Has the patient been medically treated for any type of illness during the last 3 months?
*
Yes
No
Please specify what illness
Please specify what illness
Please specify what illness
What type of treatment
What type of treatment
What type of treatment
Date of Treatment (approx)
Date of Treatment (approx)
Date of Treatment (approx)
Has the patient been to any group gathering events, like concerts, town hall meetings, social gatherings of more than 10 people or other?
*
Yes
No
Please indicate what type of event
Please indicate what type of event
Please indicate what type of event
Where was the location of this event
Where was the location of this event
Where was the location of this event
Date of the Event (approx)
Date of the Event (approx)
Date of the Event (approx)
Has the patient been tested locally for COVID-19?
*
Yes
No
Test not Available
Please indicate where
When this occurred
Results of this test
Has the patient or any close friend or family member been in self-quarantine during the last 3months?
*
Yes
No
Please indicate time frame when this occurred
Does the patient have hand sanitizer to bring with them during their travel?
*
Yes
No
I will need help obtaining this locally once I arrive
Submit Information
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