In the last 14 days, has the patient (or any member of the household) had any of the following: fever, coughing, shortness of breath, difficulty breathing, recent loss of taste or smell? *
Has the patient, a family member, or close contact had either of the following occur in the past 14 days? *
Yes
No
Diagnosis of COVID-19 infection, or any other communicable disease
Waiting on results of test for COVID-19 infection
Yes
No
Diagnosis of COVID-19 infection, or any other communicable disease
Waiting on results of test for COVID-19 infection
If Yes, please explain and include test results if applicable. (If doesn't apply, write NA)
Your answer
Has the patient been exposed to a known covid positive individual less than 6 feet away from them, for longer than 15 minutes, and without a mask?
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Has the patient been specifically asked to quarantine from school or work?
Clear selection
If the answer is yes to any of the previous questions, I understand I may be asked to reschedule this upcoming appointment and should contact the office to discuss. *
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