COVID-19 Screening Questionnaire
Happy Family Care & Clinic
Personal Information:
Full Name
*
First Name
Middle Name
Last Name
DOB
*
MM/DD/YYY
Phone Number
*
-
Area Code
Phone Number
E-mail
Have you traveled to the following countries in the past 45 days (check all that apply)
*
None
China
Iran
Korea
South Japan
Italy
Have you had close contact (being within 6 feet or that person for an extended amount of time) with a confirmed case of COVID-19 in the past 45 days?
*
Yes
No
Has a Public Health Official communicated that you were potentially exposed to COVID-19?
*
Yes
No
Have you had any of the following symptoms over that past 30 days?
*
Fever greater than 100
Cough
Troubles breathing
Shortness of breath
N/A
Do you currently have any of the following symptoms?
*
Fever greater than 100
Cough
Troubles breathing
Shortness of breath
N/A
How long have you had symptoms? Last temperature? (skip if it does not apply)
Any other symptoms you want to share with us?
Has anything been prescribed for the symptoms?
Thank You!
Please click submit below. You will be redirected to book your virtual or in-person appointment.
Submit
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