Covid Questionnaire For Patients
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Birthday
-
Month
-
Day
Year
Date
Please answer the questions below
Please ask if you need help
In the past 10 days, have you tested for COVID-19?
Yes
No
Test Date
-
Month
-
Day
Year
Date
Have you tested positive for COVID-19?
Yes
No
In the best of your knowledge, in the past 14 days, have you contacted a person who might have been COVID positive?
Yes
No
In the past 14 days, have you travelled internationally?
Yes
No
In the past 14 days, have you been advised to quarantined?
Yes
No
Do you have a fever?
Yes
No
Do you have a cough?
Yes
No
Have you experienced loss of smell or taste?
Yes
No
Do you have any difficulty breathing?
Yes
No
Do you have any level of muscle pain or body aches?
Yes
No
Do you have headache?
Yes
No
Do you have sore throath?
Yes
No
Have you been experiencing vomiting?
Yes
No
Have you been experiencing fatigue?
Yes
No
Have you been experiencing diarrhea?
Yes
No
Please check the box if you have any of the followings
Hearth disease
Lung disease
Kidney disease
Diabetes
Autoimmune disorder
Other
Submit
Should be Empty: