COVID-19 Patient Prescreening Form
Please fill out the form 48 hours prior to your appointment.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Do you have a fever or above-normal temperature (>100.4°F)?
*
Yes
No
Are you experiencing shortness of breath or having trouble breathing?
*
Yes
No
Do you have a dry cough?
*
Yes
No
Do you have a runny nose?
*
Yes
No
Have you recently lost or had a reduction in your sense of smell or taste
*
Yes
No
Do you have a sore throat?
*
Yes
No
Are you experiencing chills or repeated shaking with chills?
*
Yes
No
Do you have unexplained muscle pain?
*
Yes
No
Do you have a headache?
*
Yes
No
Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
*
Yes
No
Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
*
Yes
No
Have you been tested for COVID-19 in the last 14 days?
*
Yes
No
If you have been test for COVID-19, what is result of the test?
Positive
Negative
Still waiting on results
Have you traveled more than 100 miles from your home in the last 14 days?
*
Yes
No
Office email
example@example.com
Submit
Should be Empty: