Covid-19 (CoronaVirus) Questionnaire

Covid-19 (CoronaVirus) Questionnaire
To prevent the spread of COVID-19 and reduce the potential risk of exposure, we are conducting a simple screening questionnaire for those wishing to enter the building for appointments. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.
Date

Month Day Year
Date
Name

First Name Last Name
Phone Number

Area Code Phone Number
1. Have you returned from any of the countries listed on Coronavirus website within the last 30 days? https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html *

Yes No
2. Have you been in close contact with anyone who has traveled within the last 30 days to one of the countries listed on the CDC website? https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html *

Yes No
3. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days *

Yes No
4. Have you experienced any cold or flu-like symptoms in the last 30 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)? *

Yes No
5. By checking YES below, I do consent to having my temperature taken and understand that if my temperature is over 99* I will need to reschedule my appointment. I understand that if I check NO to consent that my appointment will be cancelled *

Yes, I consent to havig my temperature taken No, I do not consent and understand my appointment will be cancelled.
For everyone's safety, If you answered "yes” to any of the questions (except #5) you will be to contacted to change to a drop off appointment or reschedule your in-clinic appointment. Thank you for your understanding.
Signature *

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