COVID19 screening form.
Do you have any of the following symptoms?:
New and persistent cough
Shortness of breath or any difficulty breathing
Nausea, vomiting or diarrhea
Bodyaches or fatigue
Loss of taste or smell
Congestion or runny nose
Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?
Have you been in contact with anyone who has since tested positive for Covid-19?
Have you travelled abroad or out of state in the last 1-2 months? Where did you go?
Reason for Appointment:
Outside facility reports
Email lab results, phone encounter appointment, come into the office.etc
Name of person completing this form or representative assisting person.
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm