Name
*
First Name
Last Name
In the past 7 days, have you been in contact with any person actively diagnosed with COVID-19?
*
Yes
No
Have you tested positive for COVID-19?
*
Yes
No
If yes, what date did you test positive?
If yes, what is the date when you first experienced symptoms?
Have you or ANYONE you are in close contact with, experienced ANY of the following symptoms in the last 7 days?
Fever (greater than 100.4F or 38.00C)
*
Yes
No
a. Severe headache (other than injury you are here for)
*
Yes
No
b. Muscle pain (other than injury you are here for)
*
Yes
No
c. Weakness (other than injury you are here for)
*
Yes
No
d. Diarrhea/Vomiting/Abdominal Pain
*
Yes
No
e. Respiratory Illness/Shortness of Breath/Difficulty Breathing/Severe Cough
*
Yes
No
f. Loss of taste or smell
*
Yes
No
g. Sore throat
*
Yes
No
*** I agree to wear my mask properly covering my nose and mouth while in the office***
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: