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Dr Dominic Gaziano MD

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BMMC COVID 19 PRIMARY CARE COMMUNITY (TELEMEDICINE) SURVEILLANCE PROGRAM

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In an effort to help curb the COVID-19 pandemic, to connect with you to answer your questions, to help monitor and get you to the appropriate testing center (if you need testing) and to refer for treatment (if you need treatment), your clinician has put together a system to help with all these tasks.

You simply need to fill out a 5 minute questionnaire to start. All the answers are strictly confidential. This information will not only help you and your neighborhood to fight the virus as we understand it better.

There is also some information on counseling and we can connect you up with a councilor, who could help with guidance, if you’re stressed as we guard against the COVID-19 pandemic. We would also like to send you updates about the pandemic as well if you select to do so.

1 Email

2 Info

3 Symptoms

4 Exposure

5 Medical Risk Factor

6 Connect with Us

7 Almost There...

8 Thank You!

This questionnaire is intended to aid in curbing the COVID-19 pandemic. (For Research purposes only)
Email

Name
First Last
What is your sex?*
- Male
- Female
What is your birthdate?*
Which of the following best describes your race or ethnicity? (Check all that apply)*
- Asian
- Black / African American
- Hispanic / Latino
- Native American/ Alaska Native
- White/ Caucasian
- Prefer not to answer
- Other
Which state do you live in?*
Please select your Community area if you live in Chicago.
Do you have health insurance?*
- Yes
- No
Do you have a primary care physician (PCP)?*
- Yes
- No

Have you had any episode of fever (high or low grade) or feeling of warmness within the past 14 days?*
- Yes
- No
Have you had a new onset of dry cough within the past 14 days?*
- Yes
- No
Have you had any sore throat within the past 14 days?*
- Yes
- No
Have you been experiencing shortness of breath within the past 14 days?*
- Yes
- No
Have you experienced any loss of appetite within the past 14 days?*
- Yes
- No
Have you had any episode of diarrhea or loose bowel movement within the past 14 days?*
- Yes
- No
Have you experienced any disturbance of senses (smell or taste) within the past 14 days, in the absence of any environmental allergies?*
- Yes
- No

Have you had any close contact with a confirmed case of COVID-19, within 14 days?*
- Yes
- No
Have you recently visited any medical facility?*
- Yes
- No
Do you have a recent history of air travel within the past 14 days? If YES, please identify the location. If NO, please write “NONE”.*
Do you live in a building with many (10 or more) residents?*
- Yes
- No

Are you currently being treated for any medical problem? (Check all that apply. You may add any other problem not listed below.)
- Hypertension
- Diabetes Mellitus
- Cancer
- Heart Disease
- Lung Disease
- Kidney Disease
- None
- Other

Would you like us to contact you in regards to any concerns you may have about COVID-19?*
- Yes
- No
How do you prefer to be contacted?*
- Phone Call
- Text Message
- E-mail
If you prefer to be contacted via text or phone call, please enter your phone number.
If you prefer to be contacted via e-mail, please enter your e-mail address.

Would you be interested in updates on screening and monitoring of COVID-19 that apply to you?*
- Yes
- No

Stay tuned for the latest health updates on COVID-19 from our office. Our office representative will reach out to you as soon as possible (usually within 24 hours). Take care.
I hereby confirm that the information provided are true and correct to the best of my knowledge.*
- Yes
Email
This field is for validation purposes and should be left unchanged.

Body and Mind Medical Center is located conveniently next to the elevators on the first floor of St. Mary’s Professional Building. Just east on Division are the colorful restaurants, coffee shops and apparel stores in the trendy Wicker Park neighborhood of Chicago.

If labs are needed, these tests can be obtained right in the office by our experienced on site phlebotomist. Our friendly staff helps to navigate you through the sometimes challenging speciality referrals and other medical services.

Medical Office Location

Contact us

Monday – 10:00 AM – 4:30 PM
Wednesday – 10:00 AM – 4:30 PM
Thursday – 10:00 AM – 4:30 PM
Friday – 10:00 AM – 4:30 PM

2222 W. Division Street
Suite 110
Chicago, IL

For Emergency Use: (773) 252-4848

Get directions on the map →

© 2015 - Body and Mind Medical Center

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