COVID-19 Screening Questionnaire
We value your safety and the safety of our staff. Please fill out this questionnaire prior to entering our clinics. Thank you.
Email
*
example@example.com
Name
*
First Name
Last Name
Phone Number
*
Information about YOU
Which of the following symptoms have you experienced in the past 48 hours?
*
fever or chills
cough
shortness of breath or difficulty breathing
fatigue
muscle or body aches
headache
new loss of taste or smell
sore throat
congestion or runny nose
nausea or vomiting
diarrhea
I have not experienced any of the symptoms listed
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who is known to have laboratory-confirmed COVID-19 or anyone who has any symptoms consistent with COVID-19?
Yes
No
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
*
Yes
No
Have you been in close contact with a person known to have COVID-19?
Yes
No
Are you currently waiting on the results of a COVID-19 test?
Yes
No
Information about the person ACCOMPANYING/DRIVING you
Please skip this section if you drove yourself to the clinic.
Which of the following symptoms have they experienced in the past 48 hours?
fever or chills
cough
shortness of breath or difficulty breathing
fatigue
muscle or body aches
headache
new loss of taste or smell
sore throat
congestion or runny nose
nausea or vomiting
diarrhea
As far as you know, they have not experienced any of the symptoms listed
Within the past 14 days, have they been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who is known to have laboratory-confirmed COVID-19 or anyone who has any symptoms consistent with COVID-19?
Yes
No
Are they isolating or quarantining because they may have been exposed to a person with COVID-19 or are worried that they may be sick with COVID-19?
Yes
No
Have they been in close contact with a person known to have COVID-19?
Yes
No
Are they currently waiting on the results of a COVID-19 test?
Yes
No
Submit
Should be Empty: