Name of Patient: ______________________________________________
COVID19 Diagnosis YES NO
❏ Positive COVID-19 diagnosis via Nasopharyngeal Swab with no symptoms.
❏ Date _______________
❏ Positive COVID-19 diagnosis via Nasopharyngeal Swab with symptoms.
❏ Date _______________
❏ Medications ______________
❏ Hospitalized YES or NO
❏ Seen by Medical Provider
❏ Not experiencing symptoms but reports close contact with a confirmed COVID-19 case.
❏ Date of Contact _____________
❏ Experiencing symptoms and reports close contact with a confirmed COVID-19 case.
❏ Date Symptoms Ended ______________
❏ Medications ________________
❏ Hospitalized YES or NO
❏ Seen by Medical Provider
Signature _________________________________________ Date ________________
Head Athletic Trainer Team Physician:
Name: Name:
Signature: Signature:
Date: Date:
(Alfred University, Department of Athletic Training, Policies and Procedures, 2021)
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