COVID-19 Screening Questions- Insight

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In order to prevent the spread of COVID-19, protect our patients and to comply with recommendations by the CDC, please answer the following questions. If you are experiencing any symptoms consistent with COVID-19 or answer ""YES" to any of the following questions, please give us a call so that we can reschedule you or set you up with an online visit.

Email *

What is your name? *

Have you tested positive for COVID-19? *

Yes

Maybe

If you answered yes to the previous question, on what date did you test positive for COVID-19.

YYYY

Have you had close contact with or cared for someone who is suspicious for or been diagnosed with COVID-19 within the last 14 days? *

Yes

Maybe

3. Have you had any of these symptoms in the last 14 days?

Fever or Chills

Recent Sore Throat

Cough

Congestion or Runny Nose

Loss of Taste or Smell

Difficulty Breathing

Shortness of Breath

Nausea, Vomiting or Diarrhea

Recent muscle aches not associated with another health condition or exercise

I have had NO symptoms that are commonly associated with COVID-19

Other:

Submit

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