Family Healthcare of Fairfax, PC Patient Portal

Available Forms

Adult Gyn History Cryobank Covid-19 and Health Screening Form Cryobank Health History Questionnaire Cryobank Patient Registration Form Financial Policy Galleri Cancer Screening Questionnaire Health History Questionnaire HIPAA Form Immigration New Patient Registration Form Immigration Physical - Patient Health History Questionnaire New Patient Registration Form Patient Pre-Visit Covid-19 Screening Physical Exam Form

Cryobank Covid-19 and Health Screening Form

Family Healthcare of Fairfax, P.C.

WE ASK THAT YOU COMPLETE THE "SCREENING" QUESTIONS BELOW FOR THE SAFETY OF OUR STAFF, OTHER PATIENTS AND YOURSELF, PLEASE BE TRUTHFUL AND CANDID IN YOUR ANSWERS.

First and Last Name *

Date of Birth *

IN THE PAST 10 DAYS HAVE YOU BEEN IN CLOSE PROXIMITY TO OR HAD A HOUSEHOLD CONTACT WITH ANYONE WHO TESTED POSITIVE FOR COVID-19? *

HAVE YOU TESTED POSITIVE FOR COVID-19 IN THE PAST 10 DAYS? *

HAVE YOU DONE ANY RECENT TRAVEL? WHERE? WHEN? *

HAVE YOU EVER BEEN DEFERRED AS A DONOR? IF YES, WHY? *

ANY TRAVEL IN THE LAST 6 MONTHS TO ZIKA PRONE LOCATIONS? *

IN THE LAST 3 MONTHS, HAVE YOU USED NEEDLES FOR DRUGS NOT PRESCRIBED BY A DOCTOR OR HAD A BLOOD TRANSFUSION? *

IN THE LAST 3 MONTHS, HAVE YOU SHARED NEEDLES FOR DRUGS OR MEDICATION USE OR ACCIDENTALLY BEEN STUCK BY A PREVIOUSLY USED NEEDLE? *

IN THE LAST 3-6 MO., HAVE YOU HAD A NEW PARTNER, BEEN DIAGNOSED OR TREATED FOR A SEXUALLY TRANSMITTED DISEASE OR EXCHANGED MONEY FOR SEX? *

IN THE LAST 6 MO., HAVE YOU HAD A TATTOO OR BODY PIERCING? *

PLEASE LIST ALL CURRENT PRESCRIPTIONS OR SUPPLEMENTS YOU ARE TAKING. *

IF YOUR ANSWERS TO THE ABOVE QUESTIONS CHANGE BEWEEN NOW AND YOUR OFFICE VISIT, PLEASE NOTIFY US SO THAT WE CAN RESCHEDULE YOUR APPOINTMENT.

WE HAVE INSTITUTED SAFETY MEASURES IN OUR OFFICE CONSISTENT WITH PUBLISHED GUIDELINES BUT A RISK OF VIRAL TRANSMISSION REMAINS. YOUR UPCOMING MEDICAL VISIT TO OUR OFFICE IS VOLUNTARY AND WE REQUEST YOUR WRITTEN CONSENT FOR THE VISIT BY TYPING YOUR NAME AND TODAY'S DATE IN THE BOXES BELOW:

FULL NAME *

Type your full name

DATE FORM COMPLETED *

Enter date you have completed and submitted this form.

* Required field