COVID-19 Specimen Intake Form
P
lease fax completed form and attach clinical notes and any lab tests used for diagnosis and/or follow up to 909-387-6377.
If you have any additional questions or concerns, please call the Communicable Disease Section at (800) 722-4794
Patient Details MRN:
Full Name:
Age:
Date of Birth:
Address:
Primary Phone Number:
Homeless
Pregnant: Yes No Unk
Home Cell
Gender: M F MTF FTM
Primary Language:
Occupation:
Interpreter Required: Yes No
Height and Weight:
Clinical Details
Is the patient currently experiencing any of the
following symptoms:
Fever (>100.4
o
F/37
o
C)
Cough Productive Cough
Shortness of breath
NOTE: Fever present in 86% of even mild cases and
cough present in 71% of even mild cases (Li K et al
2020)
Is the patient Currently hospitalized?
Yes
No
Is the patient in an ICU setting due to ARDS?
Yes
No
Does the patient have another diagnosis/etiology
for their respiratory illness?
Yes
No
Underlying medical conditions
Asthma/chronic lung disease?
Diabetes/renal disease?
Heart or circulatory disease?
Cancer in last 12 months?
Yes No
Yes No
Yes No
Yes No
Other (specify):
Exposures
Has the patient traveled from a location with endemic spread of COVID-19 within the last 14 days?
Yes
No
If Yes, please specify:
Location:
Last Date in country with endemic spread:
Has the patient had contact with a confirmed or suspect COVID-19 case within last 14 days?
Yes
No
Has the patient had contact with anyone with an unexplained respiratory illness within last 14 days?
Yes
No
PUI#:
CDI Assigned:
CalREDIE #:
Does the patient attend/work/live in a group setting (i.e., school, hospital, long-term care facility)?
Yes
No
If yes, type of setting (school, long-term care facility,etc.)________________________________________
Name of
school/facility_______________________________________________
City______________________________________________________________
Other Testing
Have any of the following tests been performed:
Influenza Rapid Ag: Positive Negative Pending Not done
Influenza PCR Positive Negative Pending Not done
RSV: Positive Negative Pending Not done
H. metapneumovirus Positive Negative Pending Not done
Parainfluenza Positive Negative Pending Not done
Adenovirus Positive Negative Pending Not done
Rhinovirus/enterovirus Positive Negative Pending Not done
Coronavirus (OC43, 229E, HKU1, NL63) Positive Negative Pending Not done
M. Pneumoniae Positive Negative Pending Not done
C. Pneumoniae Positive Negative Pending Not done
Other, Specify
Has CBC with differential been performed?
Yes
No
If yes then is total WBC count between 3.90 and 6.03 x10(9)/L and Lymphocyte count between 0.98
and 1.5 x10(9)/L? (Li YX et al 2020)
Yes
No
Have any of the radiographic imaging been performed:
X-ray: Radiographic evidence of atypical pneumonia No evidence
Chest CT- 97% sensitivity in hospitalized patients (Tao 2020): Ground glass opacity or other
typical radiographic feature seen* No evidence
*Vascular enlargement, interlobular septal thickening, and air bronchogram sign are also common CT features of COVID-19
Submitting Physician’s name, facility name and mailing
address
Facility phone number
NPI#
Facility Fax number
Last Reviewed 03/10/2020
Li K et al, The Clinical and Chest CT Features Associated with Severe and Critical COVID-19 Pneumonia. Invest Radiology. 2020 Feb 29. doi: 10.1097/RLI.0000000000000672.
[Epub ahead of print]
Li YX et al, Characteristics of peripheral blood leukocyte differential counts in patients with COVID-19. Zhonghua Nei Ke Za Zhi. 2020 Mar 1;59(0):E003. doi: 3760.10/
cma.j.cn112138-20200221-00114. [Epub ahead of print]
Tao Ai et al, Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases, Radiology (2020). DOI: 10.1148/
radiol.2020200642
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