Coronavirus (COVID-19) Questionnaire

Contact Information
First Name*
Last Name*
Middle Initial
Address*
City*
State*
Zip Code*
Date of Birth*
Date Format: MM slash DD slash YYYY
Email*
Home Phone
Cell Phone
Employer
Supervisor
Supervisor Contact #
Supervisor Email
Medical Questionnaire

Please read: This form is intended for Coronavirus Disease (COVID-19) Risk Assessment and Public Health Management Decision Making. Each question refers to within the past 14 days.
Have you had close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset?*
Have you had close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset?
- Yes
- No
Any history of travel from or to any affected geographic areas?*
Any history of travel from or to any affected geographic areas?
- Yes
- No
If yes, where?*
If yes, where?
Do you have a fever or signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath)?*
Do you have a fever or signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath)?
- Yes
- No
Do you have a fever or signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath) requiring hospitalization?*
Do you have a fever or signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath) requiring hospitalization?
- Yes
- No
CAPTCHA

EPS Phoenix Medical Solutions, LLC.

P.O. Box 80644
Lafayette, La, 70598
Phone: 337-445-1015

925 W. Daggett St.
(Corner of W. Daggett & Eddy St.)
Pecos, TX 79772
Phone: 432-447-1910
Email: pecosclinic@epsphoenix.com

Frank Stoltz, Operations Manager
Direct: 337-445-1015
Mobile: 337-380-2804
Email: fstoltz@epsphoenix.com