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COVID-19 Signs and Symptoms:
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Patient's Name (Last, First):
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Your answer
Date of Birth:
MM
/
DD
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YYYY
In the past 10 days
*
1. Tested Positive for COVID-19 or waiting on the results of a COVID-19 Test
2. Been designated a contact of a person who tested positive for COVID-19 by a local health department
3. Traveled internationally to a COVID-19 high rise area (CDC level 2 or 3)
None of the above
https://coronavirus.health.ny.gov/covid-19-travel-advisory#restricted-states
PLEASE CHECK OFF IF CURRENTLY OR IN THE LAST 14 DAYS HAS ONE OR MORE OF THESE NEW OR WORSENING CONDITIONS
*
4. Temperature greater than or equal to 100F (37.8c)
5. Feeling feverish or have chills
6. Cough
7. Loss of taste or smell
8. Fatigue/feeling of tiredness
9. Sore throat
10. Shortness of breath or trouble breathing
11. Nausea, vomiting, diarrhea
12. Headache
13. Nasal congestion/runny nose
None of the above
Other:
Do you acknowledge and accept the risk of exposure in our office to a communicable disease, included but COVID-19, and consent to treatment?
Yes
No
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By Checking this box: I acknowledge all preceding answers are true and correct. This serves as my electronic signature. (Parent or Guardian if minor)
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