Gannon Health Screening Questionnaire

Gannon Health Screening Questionnaire
Name*

First (Given) NameLast Name (Surname)
Risk
Birth Date*

MonthDayYear
Gannon Email Address*
(This sends the results to your email, enabling documentation.)
Gannon ID Badge#*
(First SEVEN Digits)
Phone Number*

Area CodePhone Number
Affiliation*
Primary Complaints:*

AllergiesBack PainCough/ColdEye IrritationFeverMuscle AcheNasal Congestion/Sinus PainHeadacheEar Discomfort/PainSore ThroatNausea/VomitingUrinary SymptomsSkin Condition
Injury: (explain)
Other: (explain)
Campus Location:
Would you like to be seen in the health center?

YesNo
Best Appointment Times:
Please feel free to simply walk-in to the Health Center to be seen M-F 8-12 or 1-4:30 (except for Gannon designated holidays), call the front desk at 814-871-7622 for assistance, or indicate in the "Best Appointment Times" text box a few different times that work best for an appointment today. We will let you know if we have any openings that match your availability as well as offer any appointment times slots we do have open. We welcome walk-in appointments and will do our best to accommodate you in a timely manner. Depending on the availability of our provider/nurses, walk-in appointments may have a short wait time if patients with standing appointments are being seen.

Once you submit this questionnaire, a nurse may be in contact with you by email or phone if needed, normally within a few hours (except for when the center is closed), to gather more information and/or to confirm an appointment time.

Our nurses can run tests such as COVID, Strep, and Flu and our nurse practitioners can provide prescription medications for a very small fee in the HC if indicated. If needed, we can also provide a care package of over-the-counter items free of charge to help you feel better.

For non-emergency immediate on-demand medical care during times the Health Center is closed, please remember students can use the TimelyCare Telehealth app which is also accessible as an option on your LiveSafe app or online at timelycare.com/gannon, 24 hours a day, 365 days a year.

For emergency situations, please visit the nearest emergency room or if transport or ambulance is needed call 814-871-7777 if on campus or 911 for assistance.
Once you submit this questionnaire, a nurse will be in contact with you by email normally within a few hours (except for when the center is closed over lunch, on holidays, and weekends), to discuss your symptoms and support measures, and may gather additional information to best assist you.

For non-emergency immediate on-demand medical care during times the Health Center is closed, please remember students can use the TimelyCare Telehealth app which is also accessible as an option on your LiveSafe app or online at timelycare.com/gannon, 24 hours a day, 365 days a year.

For emergency situations, please visit the nearest emergency room or if transport or an ambulance is needed call 814-871-7777 if on campus, or call 911 for assistance.
Have you traveled outside of Pennsylvania for 24 hours or more, without being fully vaccinated or having tested positive for Covid in the last 90-days, since the last time you completed this survey?*

YesNo
Once you submit this questionnaire, a nurse will be in contact with you by email normally within a few hours, typically during the workday, to gather more information about your situation. If you are reporting a positive home test, please write your name and test date on the test itself and email a picture image to health@gannon.edu while you are awaiting contact from a nurse. Please email any other positive test you are reporting to this email address as well, for example, one completed by a pharmacy or doctor's office. If you need to speak with a medical provider while the health center is closed, students can use the TimelyCare Telehealth card on your LiveSafe app or go to timelycare.com/gannon to meet with a provider for medical care now.
Date

YearMonthDay
DateHourMinutesAM/PM Option
I certify all the information provided is shared to the best of my ability.
Should be Empty: