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COVID Patient Screening
We appreciate your taking the time to complete our COVID screening in advance of your visit to our office. These questions will be repeated on your arrival to ensure nothing has changed since you completed this questionnaire.
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Your full name:
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Your answer
Please check symptoms experienced currently or lately (last 14-21 days)
Fever
Difficulty breathing or shortness of breath
Cough
Sore throat
Gastrointestinal upset, nausea, vomiting, diarrhea
Unusual fatigue
Chills
Muscle pain
Headache
New loss of taste or smell
Rash or blotchy areas on body
Other:
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