COVID-19 Screening Questionnaire

COVID-19 Screening Questionnaire

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

Rows	Yes	No
Cough
Shortness of breath of 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 office. You should:
- Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)
- See your PMD

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 offfice. 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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: