COVID-19 Screening Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete the following questionnaire within the 24 hours prior to your appointment.

Email *

First & Last Name *

Today's Date *

YYYY

1. Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea and vomiting, or diarrhea?

Yes

Clear selection

2. Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?

Yes

Clear selection

3. Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?

Yes

Clear selection

4. Is anyone in your household isolating or quarantining because they may have been exposed to a person with COVID-19 or are worried that they may be sick with COVID-19?

Yes

Clear selection

5. Are you currently waiting on the results of a COVID-19 test?

Yes

Clear selection

6. Have you traveled outside of Ohio in the past 30 days?

Yes

Clear selection

Clear form

Never submit passwords through Google Forms.

This form was created inside of Practical Healing. Report Abuse

Forms