COVID-19 Outpatient Trial
Screening Form
Participant Information
Full Name
Date of Birth
Contact Number
Email Address
Address
Screening Questions
Date of Symptom Onset
Positive COVID-19 Test Date
Current Symptoms
Eligibility Criteria
Are you currently hospitalized?
No
Yes
Have you participated in another COVID-19 trial?
No
Yes
Medical History
Relevant Medical Conditions
Current Medications
For Staff Use Only
Screened By
Date of Screening
Eligibility Status
Eligible
Not Eligible
Pending
Comments