JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Patient Pre-Sick Visit Screening Questionnaire
Please complete
* Indicates required question
Email
*
Your email
Patient name
*
Your answer
Phone number
*
Your answer
Date of appointment
*
MM
/
DD
/
YYYY
Have you, your child, or anyone in the household traveled in the past 14 days?
*
Yes
No
Have you, your child, or anyone in your household had a known exposure to coronavirus in the past 14 days?
*
Yes
No
Have the parent or adult accompanying the patient been sick in the past 14 days?
*
Yes
No
What is the current temperature of the adult accompanying the patient?
*
Your answer
Has you, your child, or anyone in your household had a COVID test in the past 14 days? If yes, what was the result?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
