www.quincysmilecenter.com/ - Covid-19 Patient Questionnaire

Covid-19 Patient Questionnaire
1. Have you traveled overseas since January 2020 or to a highly infected area?*

YesNo
2. Have you had close contact with anyone with a confirmed Covid-19 in the last 14 days?*

YesNo
3. Have you had any of these symptoms in the last 14 days?
Fever over 100 degrees F?*

YesNo
Difficulty breathing (shortness of breath)?*

YesNo
Cough?*

YesNo
Sore throat?*

YesNo
Loss of taste or smell?*

YesNo
Flu like symptoms? Chills, nausea, vomiting, diarrhea*

YesNo
Fatigue?*

YesNo
Body aches?*

YesNo
4. Have you had any Covid-19 test?*

YesNo
If Positive result date

MonthDayYear
Date
If Negative result date

MonthDayYear
Date
Test for antibodies?

YesNo
If YES what were the results

YES ANTIBODIESNO ANTIBODIES
Any more information you would like to provide?
Signature*

Clear
Patients Name*

First NameLast Name
Date*

MonthDayYear
Date
Thank you for helping us, to help you!
Dr. Stephen Matarazzo
Should be Empty: