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Metro Health COVID-19 Screening
The following is Metro Health's Coronavirus (COVID-19) Screening form prior to an appointment. Please complete the entire form honestly. Thank you!
Metro Health Team
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Name: (First, Last)
Your answer
Date:
MM
/
DD
/
YYYY
Over the past 48 hours, have you experienced any of the following symptoms: Check all that apply
Yes
No
Fever or Headache
Shortness of Breath of Difficulty Breathing
Dry Cogh
Sneezing/Runny Noe
Muscle Pain, not due to exercise
Chills or repated shaking with chills
Loss of Smell or Taste
Any feeling of fever or temperature>99.5
Yes
No
Fever or Headache
Shortness of Breath of Difficulty Breathing
Dry Cogh
Sneezing/Runny Noe
Muscle Pain, not due to exercise
Chills or repated shaking with chills
Loss of Smell or Taste
Any feeling of fever or temperature>99.5
Have you or anyone in your household: Tested Positive or Negative for COVID 19 in the last 14 days/
Yes
No
Clear selection
If positive, please elaborate?
Your answer
Have you traveled outside of DC, MD, or VA or outside of the country in the last 14 days?
Yes
No
Clear selection
If yes, please elaborate
Your answer
Please describe any other symptoms you are experiencing:
Your answer
If you are having symptoms, any action taken by you?
Your answer
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