COVID-19 QUESTIONNAIRE
Date
-
Month
-
Day
Year
Date
HAVE YOU BEEN TESTED FOR COVID-19?
Yes
No
If yes, what was the date of the test?
-
Month
-
Day
Year
Date
Results
Negative
Positive
Have you been in contact with anyone awaiting their test results?
Yes
No
Have you been in contact with anyone who tested positive?
Yes
No
Do you hae any of the following symptoms?
Coughing
Sore Throat
Headaches
Fever
Shortness of Breath
Runny Nose
Diarrhea
Patient Name:
Patient Signature
Submit
Should be Empty: