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COVID-19 Questionnaire
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7
Questions
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1
Patient Name
*
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First Name
Last Name
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2
Date of Birth
XX/XX/XXXX
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3
Please tell us what brings you in today
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4
Have you been in contact with a confirmed case of COVID -19 within the last 14 days?
*
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YES
NO
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5
Are you currently exhibiting symptoms of cough, fever, body aches, sore throat, or shortness of breath, OR do you have anyone in your household with symptoms of cough, fever, body aches, sore throat, or shortness of breath?
*
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YES
NO
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6
Attestation
*
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I attest that all of the above information is true to the best of my ability.
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7
Signature
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