COVID-19 Patient Screening Questions
These questions are being used as a screener to help prevent the spread of COVID-19. It is not meant to confirm suspected cases of COVID-19. Please fill out this questionnaire as the patient. If you are suspected of having COVID-19 or being exposed to COVID-19 we may ask you to reschedule your appointment. Thank you for your cooperation!
Has anyone in your household traveled in the past 72 hours?
Do you have any of the following?
Shortness of breath
Repeated shaking with chills
New loss of taste or smell
Are you or anyone in your household ill?
No, I am NOT ill
Yes, I am ill
Yes, someone who lives with me is ill
Should be Empty: