Covid-19 Patient Screening Form
Patient Name
First Name
Last Name
Have you received your COVID Vaccine yet?
*
Please Select
YES
NO
Which Vaccine did you have?
Date of 1st Vaccine
-
Month
-
Day
Year
Date
Date of 2nd Vaccine
-
Month
-
Day
Year
Date
Date of Booster
-
Month
-
Day
Year
Date
1. Do you have a fever or felt hot and feverish within the last 14-21 days?
Please Select
YES
NO
2. Are you having shortness of breath or any difficulty breathing?
Please Select
YES
NO
3. Do you have a cough?
Please Select
YES
NO
4. Any other flu-like symptoms, headache or fatigue?5. Have you experienced any loss of taste or smell?
Please Select
YES
NO
5. Have you experienced any loss of taste or smell?
Please Select
YES
NO
6. Have you been in contact with anyone who has confirmed COVID?
Please Select
YES
NO
7. Are you over 60?
Please Select
YES
NO
8. Do you have heart, lung or kidney disease?
Please Select
YES
NO
9. Do you have Diabetes or Autoimmune disorders?
Please Select
YES
NO
Please sign
*
Clear
Date
*
-
Month
-
Day
Year
Date
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