• Covid-19 Patient Questionnaire

  • 1. Have you traveled overseas since January 2020 or to a highly infected area?*
  • 2. Have you had close contact with anyone with a confirmed Covid-19 in the last 14 days?*

  • 3. Have you had any of these symptoms in the last 14 days?

  • Fever over 100 degrees F?*
  • Difficulty breathing (shortness of breath)?*
  • Cough?*
  • Sore throat?*
  • Loss of taste or smell?*
  • Flu like symptoms? Chills, nausea, vomiting, diarrhea*
  • Fatigue?*
  • Body aches?*
  • 4. Have you had any Covid-19 test?*
  • If Positive result date
     - -
    2 digit month, 2 digit day, 4 digit year
  • If Negative result date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Test for antibodies?
  • If YES what were the results
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Thank you for helping us, to help you!
    Dr. Stephen Matarazzo

  • Should be Empty: