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PATIENT - COVID-19 SCREENING FORM
Please fill out and submit this form to complete prescreening.
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1
APPOINTMENT DATE
*
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-
Date
Year
Month
Day
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2
PATIENT NAME
*
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First Name
Last Name
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3
PHONE NUMBER
*
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Please enter a valid phone number.
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4
Do you have any of the following symptoms?
*
This field is required.
Select NONE OF THE ABOVE if you DO NOT have a fever AND symptoms have been improving for 24 hours.
Fever and/or chills
Cough
Loss of taste or smell
Shortness of breath
Sore throat
Runny nose
Muscle aches or joint pain
Headache
Extreme Tiredness
Nausea/Vomiting/Diarrhea
Abdominal pain/Decreased Appetite
Pink Eye
None of the above
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5
Have you been told that you should be quarantining or isolating?
*
This field is required.
By a doctor or government authority.
YES
NO
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6
Have you tested positive for Covid-19 in the last 10 days?
*
This field is required.
On a PCR test or rapid test.
YES
NO
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