In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire. Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and our employees.

Patient Name:

Patient Date of Birth:

Phone Number:

Screening Questions

Are you currently experiencing, or have you experienced in the past 10 days, any of the following symptoms? (Please take your temperature before you answer this question.)

YesNoFever (100.4° F/37.8° C or greater)

YesNoCough

YesNoShortness of breath or difficulty breathing

YesNoSore throat

YesNoNew loss of taste or smell

YesNoChills

YesNoHead or muscle aches

YesNoNausea, diarrhea, vomiting

YesNoFever (100.4° F/37.8° C or greater)

In the past 10 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

YesNo

Have you been tested for COVID-19 and are waiting to receive test results?

YesNo

Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?

YesNo

In the past 10 days, have you been on a commercial flight or traveled outside of the United States?

YesNo

In the past 10 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?

YesNo

I agree to notify the practice if within 10 days I become ill with COVID-19 symptoms or test positive for COVID-19.

Your Signature

Date:

Thank you! Your submission has been received!

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