Patient Name
*
Patient Date of Birth
*
-
Month
-
Day
Year
Today’s Date
*
-
Month
-
Day
Year
Temperature Reading
*
Must be below 100.4 degrees
Do You Currently, or Have You Experienced Within the Past 14 Days, Any of the Following Symptoms?
Coughs
*
Yes
No
Difficulty Breathing/Shortness of Breath
*
Yes
No
Fever
*
Yes
No
Sore Throat
*
Yes
No
Loss of Smell or Taste
*
Yes
No
Diarrhea, Nausea, or Other GI Symptoms
*
Yes
No
In The Past 14 Days, Have You Been in Contact With a Known COVID-19 (Coronavirus) Patient?
*
Yes
No
Have You Traveled Outside The United States by Air or Cruise Ship in the Past 14 Days?
*
Yes
No
Have You Traveled Within the United States by Air, Bus or Train Within the Past 14 Days?
*
Yes
No
Submit
Should be Empty: