COVID-19 SELF ASSESSMENT - Allied Physicians Group

Have you tested positive with a PCR or rapid COVID- 19 test within the past 10 days?

Yes No

Were you exposed to someone who tested positive for COVID-19?

True exposure is defined as:

– Being with the positive individual within 6 feet for more than 15 minutes cumulatively within a 24-hour period

AND

– The above exposure occurring during their illness OR within the 48 hours prior to their symptoms presenting OR within the 48 hours prior to their positive COVID-19 test (if they were asymptomatic to testing).

Yes No

Do you have 2 or more low-risk symptoms OR 1 or more high-risk symptoms?

Low-Risk: General Symptoms (2 or more)

– Fever (≥100.4°F)
– Congestion/Runny Nose
– Nausea/Vomiting/Diarrhea
– Sore Throat
– Headache
– Fatigue/Muscle or Body Aches

High-Risk: Red Flag Symptoms (1 or more)

– Cough (new onset affecting quality of life)
– Difficulty Breathing
– Loss of Taste/Smell

Yes No

Submit your assessment now.

Do you have 2 or more low-risk symptoms OR 1 or more high-risk symptoms?*

Low-Risk: General Symptoms (2 or more)

– Fever (≥100.4°F)
– Congestion/Runny Nose
– Nausea/Vomiting/Diarrhea
– Sore Throat
– Headache
– Fatigue/Muscle or Body Aches

High-Risk: Red Flag Symptoms (1 or more)

– Cough (new onset affecting quality of life)
– Difficulty Breathing
– Loss of Taste/Smell

Yes No

Are you fully vaccinated?

You are considered fully vaccinated if you have been boosted or completed a primary series of Pfizer or Moderna vaccines within the last 6 months. You are also considered fully vaccinated if you been boosted or have received the primary vaccine of Johnson & Johnson within the last 2 months.

Yes No