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COVID Intake Form
This form is used by the Noble County Health Department, Caldwell Ohio, to determine start of isolation dates for residents who are positive for Covid-19. It will also help us recommend quarantine dates for your close contacts.
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Email
*
Your answer
Testing Location
Marietta Memorial
SEORMC
Genesis/ Healthplex
Dr. Spencer/ Jake Biedenbach NP
Becky Hall CNP
MVHC - Cambridge
Cambridge Urgent Care
Gillespies Drugs
Nursing Home Testing
School Testing
Employer Testing
Home Test - proctored (a trained person helped you take the test)
Home Test - not proctored
Other:
Clear selection
What is the expiration date on the home test? (if you took a home test.)
MM
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DD
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First Name of Positive Case
*
Your answer
Last Name of Positive Case
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
What is the best phone number to reach you?
*
Your answer
Date of Birth
*
MM
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DD
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YYYY
Race
White
American Indian
Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Prefer not to answer
Other:
Clear selection
Ethnicity
Not Hispanic or Latino
Hispanic or Latino
Prefer not to answer
Clear selection
Are you submitting this form for yourself or a family member?
*
Self
Child
Parent
Spouse
Other:
Have you had any of the following symptoms since becoming sick with COVID?
*
No Symptoms
Cough
Shortness of Breath
Dyspnea/ Runny Nose/ Congestion
Conjunctivitis (eye redness)
Muscle Aches
Nausea/ Vomiting
Difficulty Breathing
Fever
Sore Throat
Chills
Issues with Taste or Smell
Headache
Diarrhea
Abdominal Pain
Fatigue
Other:
Required
When did symptoms first appear? If you did not have symptoms, enter your test taken date. Note: Minimum of 2 symptoms. For example, headache and sore throat, or cough and runny nose, etc
*
MM
/
DD
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YYYY
Over the last 24 hours, have your symptoms improved?
Yes
No
Maybe
Clear selection
Help us identify close contacts that you may have exposed who should be quarantined. Please let us know if they are aware that you are positive with COVID. A contact is considered anyone that you were around within 6 feet for more than 15 minutes, starting 48 hours prior to your illness onset (48 hours prior to test date if you are asymptomatic). Please List:
Your answer
Where do you work or go to school? Please include grade and teacher or any other specific information. Are you involved in any extra curricular activities or sports?
Your answer
What were the dates you were last at work, school or activities?
Your answer
Were you vaccinated for Covid19?
Your answer
Do you know how you may have been exposed?
Your answer
Have you attended any Mass Gatherings?
No
Yes - Wedding
Yes - Funeral
Yes - Party
Yes - Family Dinner
Yes - Other
Clear selection
Have you recently traveled?
Yes
No
Clear selection
Do you have any Health Conditions?
Ashtma
Cardiovascular Disease
Diabetes
High Blood Pressure
Immunocompromised condition
Current or Former Smoker
None
Prefer not to answer
Other:
Clear selection
Guardian's Name (if applicable)
Your answer
Do you have a close contact that will need a work or school letter in order to quarantine?
Yes
No
Clear selection
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