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Patient Pre- Well Visit Screening Questionnaire
Please complete questionnaire 48 hours prior to your child's appointment
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* Indicates required question
CHILD'S FIRST AND LAST NAME
*
Your answer
PHONE NUMBER
*
Your answer
Date of Appointment (NOT Date of Birth)
*
MM
/
DD
/
YYYY
Today's date
*
MM
/
DD
/
YYYY
Have you, your child, or anyone in your household felt sick today or in the past 14 days? If yes, who and how?
*
Your answer
Is anyone in the household experiencing any of these symptoms
*
fever
Cough
congestion
Chills
shortness of breath or difficulty breathing
fatigue
muscle or body aches
headache
loss of taste or smell
sore throat
nausea or vomiting
diarrhea
stomachache
Other
None of the above
Required
What is your child's temperature?
*
Your answer
What is the temperature of the adult accompanying the child?
Your answer
Have you, your child, or anyone in your household engaged in any at-risk behaviors according to the CDC or local guidelines?
*
Yes
No
If yes, What? and When?
Your answer
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