Covid 19 questionnaire

Covid-19 Questionnaire
Name *

First Name Last Name
Are you experiencing any of the following symptoms? Cough, Shortness of breath, or fever *

Cough Shortness of breath Fever None of the above
Have you been in contact with someone who had the flu, respiratory illness, or Coronavirus in the last 14 days? *

Yes No
Have you traveled outside of PA in the last 14 days? If so, please contact our office. *
Should be Empty:

Covid-19 Questionnaire