COVID 19 Questionnaire for Arriving Patients
This survey is intended for any and all patients arriving at our office. Please respond carefully to each question below. Thank you for helping us keep our patients and staff safe during these uncertain times - Lloyd Takao, MD, Pediatrics
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Date of Appointment
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Patient/Parent Name *
Are all the parents and children over 5 years old in you household vaccinated against COVID-19? *
Have you had any close calls or COVID scares in the past 2 weeks? *
Has anybody in your household had any of fever, chills, or fatigue in the last 72 hours? *
Any COVID testing in the last 2 weeks? *
If yes, please list the date(s) and result(s) of the tests
Has the patient or any parent been on public transit or an airplane in the past 2 weeks? *
In the past two weeks, has your child or any parent been with any unvaccinated groups in an enclosed space without a mask? *
If yes to the prior question, have you been tested for COVID-19 since your return?
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Do all the children in your household under 12 years old wear masks in all enclosed areas? *
In the last 2 weeks, has the patient or any parent been in a group of 20 or more people, not including classes at school or daycare? *
If the answer to the above question is yes: Did they require proof of vaccination or a negative COVID test?
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Notes from any question?
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