Covid-19 Health Declaration

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

Please complete the following questionnaire a maximum of 24 hours before your scheduled appointment.

Email *

Are you currently experiencing any of the following symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. *

Fever and/or chills? Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup) continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

Shortness of breath. Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Sore throat. Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have

Difficulty swallowing? Painful swallowing (not related to other known causes or conditions you already have)

Runny or stuffy/congested nose Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Decrease or loss of taste or smell. Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Pink eye. Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)

Headache, unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Digestive issues like nausea/vomiting, diarrhea, stomach pain. Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have

Muscle aches, unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Extreme tiredness, unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

None of the above

I haven't been in close contact with someone who is sick or has tested positive with Covid-19 within the past 14 days

I haven't traveled outside the Country within the past 14 days

Required

I have answered the above questions truthfully and best to my knowledge. *

Yes

YYYY

Please type your name. *

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms