COVID-19 Screening Questionnaire
You will be asked the same questions upon arrival at the office.
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Covid-19 Screening questions. Please check if you have experienced any of the following:
Have you had close contact with anyone with an acute respiratory illness?
Have you been in close contact with a confirmed case of COVID-19?
Do you have any of the following symptoms? Check all that apply:
Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
A decrease or a loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches(myalgia)
Nausea/vomiting, diarrhea, abdominal pain, pink eye(conjunctivitis)
Runny nose/nasal congestion without other known cause
Are you 70 years of age or older and experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
Yes
No
Have you been in any social gathering with more then 10 people who are not a part of normal social circle in the past 2 weeks?
Yes
No
Submit
Should be Empty: