COVID19 Self Assessment Questionnaire

COVID19 Self Assessment Questionnaire

This questionnaire must be completed prior to your scheduled appointment time.
Name

First Name Last Name
Appointment Date & Time
1. Are you experiencing any of the following:
- Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
- Severe chest pain
- High fever
- Chills
- Sore throat
- Fatigue
- Headache
- Loss of taste or smell
- Congestion or runny nose
- Nausea, vomitting or diarrhea
YES NO
2. Have you been tested for Covid19 in the past 14 days?

YES NO
3. Have you had close contact with anyone who has tested positive for Covid-19 in the past 14 days?

YES NO
Should be Empty: