Wellness Form
Patient Name:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Do you have a cough?
*
Yes
No
Do you have a fever now or have you in the past 14-21 days?
*
Yes
No
Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?
*
Yes
No
Are you experiencing shortness of breath or difficulty breathing?
*
Yes
No
Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
*
Yes
No
Have you experienced recent loss of taste or smell?
*
Yes
No
Are you over the age of 60?
*
Yes
No
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
*
Yes
No
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
*
Yes
No
Submit
Should be Empty: