0920-1011 COVID-19 Test Request Form

5/7/2020

COVID-19 Test Request Form

COVID-19 Test Request Form
Do you have a PUI Number for this request?
Yes
No
2nd Unique ID / PUI # *

LA2020
PUI # should start with "LA2020" and include at least 4 additional characters.

2nd unique ID entered above must be present on sample
Hospitalization Status and Symptoms

This patient is: (check all that apply) *
Hospitalized?
Admitted to ICU?
Intubated (Mechanical Vent)?
ER Visit Only?
None of the Above
Symptoms Reported *
Fever, include temperature below
Sore Throat
Chills
Abdominal Pain
Cough
Shortness of Breath
Headache
Runny Nose
Vomiting
Diarrhea
Muscle Aches
https://appengine.egov.com/apps/la/LDH/Covid-19_Test_request

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COVID-19 Test Request Form

ARDS
Abnormal Chest X-Ray
Pneumonia, specify below
Other, specify below
None of the Above
Has testing been done to rule out other respiratory illnesses? *
Yes
No
Influenza? *
Not Done
Negative
Positive
Pending
Respiratory Virus Panel? *
Not Done
Negative
Positive
Pending
Blood Cultures? *
Not Done
Negative
Positive
Pending
Other Tests? *
Not Done
Negative
https://appengine.egov.com/apps/la/LDH/Covid-19_Test_request

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COVID-19 Test Request Form

Positive
Pending
Does the patient have any comorbid conditions? *
Yes
No

Step 1 of 5

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https://appengine.egov.com/apps/la/LDH/Covid-19_Test_request

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