COVID-19 Screening Questionnaire

You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT come or enter the clinic buildings.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps .

1) Have you had any of the following symptoms in the last 24 hours?*

Rows	Yes	No
Cough
Shortness of breath or difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:*

Rows	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

If you answered “Yes” to question one, please DO NOT come into the clinic. and contact your healthcare provider immediately.

2) In the last 14 days have you:*

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT come into the clinic. You should self-quarantine for at least 14 days.

I certify to the best of my knowledge; this information is accurate.

Signature*

Name*

First NameLast Name

Date*

Date