Language
English (US)
Naturopathic Family Medicine and Nutrition Center, LLC
2 Corporate Drive, Unit 112, Trumbull, CT 06611
COVID-19 Questionnaire
Please complete 24 hours prior to your appointment.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Have you had a confirmed case of COVID-19?
*
Yes
No
Have you been vaccinated for COVID-19?
*
Yes, 1st shot of Pfizer or Moderna
Yes, both shots of Pfizer or Moderna
Yes, single shot of J and J
No
In the past 14 days, I have experienced...
*
Yes
No
Fever 101°F +
Unexplained body aches or pain
Coughing
Sore throat
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on toes/feet
Unusual fatigue
Non-allergy related runny nose
Exposure to COVID-19
Diagnosis with COVID-19
International Travel
Travel out of state
Out of state visitors
Diarrhea
If you have answered yes to any of the above questions, please explain below:
Signature
Clear
Submit
Should be Empty: