COVID19 PATIENT QUESTIONNAIRE
NOTE: This form should be filled out and submitted 48 hours prior to your travel date to Costa Rica. Please fill out all parts completely. All information is completely confidential.
Date
*
-
Month
-
Day
Year
Date
Complete Name
*
First Name
Last Name
Email
*
example@example.com
Patient Coordinator: Please select one
*
Please Select
Dr. Carlos Fiorito
Dr. Karen Yurell
Milena Chaves
Sue Hallstrom
Ronald Rojas
Ana Morales
Alejandra Fernandez
Do you / or anyone you will be traveling with have a fever or felt hot or feverish the last 14-21 days?
*
Yes
No
If "Yes", please write the temperature below:
Do you / or anyone you will be traveling with have shortness of breath or trouble breathing?
*
Yes
No
Do you / or anyone you will be traveling with have a cough?
*
Yes
No
Do you / or anyone you will be traveling with have any other flu-like symptoms, such as gastro-intestinal upset, headache or fatigue?
*
Yes
No
Have you / or anyone you will be traveling with experienced loss of taste or smell?
*
Yes
No
Have you / or anyone you will be traveling with been in contact with any confirmed COVID-19 positive patients? Patients who are well but have a sick family member at home with COVID-19 should consider postponing elective treatment.
*
Yes
No
Are you / or anyone you will be traveling with over the age of 60?
*
Yes
No
Do you / or anyone you will be traveling with have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
*
Yes
No
If so, what:
Submit
Should be Empty: