GUAM PUBLIC HEALTH LABORATORYDEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES
761 South Marine Corps Drive, Tamuning, Guam 96913
Telephone: (671) 300-9085/9096/9097/9098 Fax: (671) 300-9989

GPHL LABORATORY NUMBER
DATE RECEIVED(PLEASE TYPE INFORMATION AND OR PRINT LEGIBLY)
ORDERING/PRIMARY PHYSICIAN:I. PATIENT IDENTIFICATIONLAST NAME
Robert Leon Guerrero, M.D. or designee
ADDRESS: DPHSSNRCHCTIYAN OUTREACH

520 WEST SANTA MONICA AVENUE
DEDEDOState:GUAM
Zip Code: 96929
Country:USA
Phone No.: (671) 635-7525

Street:City:

FIRST NAME AND MIDDLE INITIALRESIDENT ADDRESS (Physical place of residence Street, City, Zip Code)Street:SUBMITTING LABORATORY:City:

ADDRESS:Street:City:

State:Country:

Zip Code:

Zip Code:

PHONE NO.:
Cell/Mobile:
EMPLOYER / OCCUPATION

Home:
Work:
DATE OF BIRTHETHNICITY(e.g. Chamorro, Filipino, etc.)

Phone No.:
CLINICAL DIAGNOSISDATE OF ONSETCATEGORY OF AGENT SUSPECTED

SPECIFIC AGENT SUSPECTED

II. SPECIMEN INFORMATION
1. SOURCE OF SPECIMEN
5 HUMANOTHER (Specify):SEXLABORATORY EXAMINATION REQUESTEDCOVID-19/SARS-COV-2-PCR

4. SEROLOGY OF SPECIMEN
PURE ISOLATEMIXED CULTURE

III. CLINICAL HISTORY
1. CLINICAL SIGNS AND SYMPTOMSFEVER
EXANTHEMA (Specify Type):

OTHER (Specify):
2. ORIGINAL MATERIALTYPE OF SPECIMEN (SPECIFY SITE OF COLLECTION):
NASOPHARYNGEALDATE OF ORIGINAL CULTURE:RESPIRATORY SIGNS:PRIMARY ISOLATON MEDIA:COLLECTON SITE OF ORIGINAL SPECIMEN:

CENTRAL NERVOUS SYSTEM INVOLVEMENT:DATE AND TIME OF COLLECTION:

TRANSPORT MEDIUM:DATE OF CULTURE SUBMITTED AND TRANSPORT MEDIUM
USED:COLLECTED BY (PRINT NAME):SUSPECTED IDENTIFICATION:RN/LPN/CNA
3. SEROLOGY OF SPECIMENCOLLECTION DATE:ACUTE (S1):GASTROINTESTINAL INVOLVEMENT:

2. ADDITIONAL INFORMATIONTRAVEL HISTORY:OTHER ORGANISMS FOUND:OTHER INFORMATION:CONVALESCENT (S2):IMMUNIZATIONS:
Pfizer
1st Dose

YES

Moderna 1st Dose
Janssen Single DoseANTIBIOTIC THERAPY:

S3:
S4:

NO
2nd Dose
2nd Dose

OTHER (Specify):
DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES BCDC GPHL USE ONLYAssay:

3. PREVIOUS LABORATORY RESULTS/OTHERINFORMATION

Result:DATE OF REPORT:________________________REFERENCE VALUES: NEGATIVE OR NOT DETECTED

FORM GPHL (GPHL CLIA#: 65D0662216)
DPHSS_FRM_03/12/20/REV04/25/2020_Ver.NRCHC/CRHC_09/05/2020_Rev.M.D.02/22/2021

The instrumentation used to conduct thetest has significant sensitivity. Neverthelessfew negative results should be treated withcaution. Patient follow up and repeat testing,if clinically indicated, are recommended.

Patient Last Name: ___________________________ Patient First Name: _______________________Date of Birth: __________________

COVID-19 Form for Testing/Outreach/Mass Screening
Date of onset: _______(if symptomatic) Date of travel:_______(if history stated)
During this illness, did the patient experience any of the following symptoms?
SYMPTOMS
Fever >100.4F (38C)
Subjective fever (felt feverishChills
Muscle aches (myalgias)
Runny nose
Sore throat
Cough (new or worsening)
Shortness of breath
Nausea or vomiting
Headache
Abdominal pain
Diarrhea
Loss of sense of smell or taste or appetite
Congestion
Fatigue/weakness
Rash
Other (specify):

YESNOYESNO

Does the patient have any pre-existing medical conditions?
CONDITION
Chronic lung disease (asthma, emphysema, COPD)
Diabetes mellitus
Cardiovascular disease
Hypertension only (high blood pressure)
Chronic renal disease (ESRD/CRI)
Chronic liver disease
Immunocompromised condition (cancer, chemo, lupus, HIV etc).
Neurological/neurodevelopmental/intellectual disability
Hepatitis
Current Smoker
Former smoker
For Females, is patient currently pregnant?
Other (specify):

Contact with another lab-confirmed COVID-19 patient? Yes ____No____Type of Contact: □Household □Community □Workplace □Healthcare
Previous COVID-19 testing? Yes ___No___ If “Yes”, Date of collection:________ Result:______Name of Interviewer: Last _____________________________ First ____________________________
Date of Interview: ______________________

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