COVID-19 Screening Questionnaire

COVID-19 Screening Questionnaire
If you experience any symptoms or answer “YES” to any of these questions, please cancel your appointment and contact your health care professional for recommended next steps.

1) Have you had any of the following symptoms in the last 24 hours? *

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours: *

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

2) In the last 14 days have you: *

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone or cared for someone who had COVID-19 symptoms?
Traveled internationally or to any other state for an extended visit?
Been tested for COVID-19 and are the results still pending?

If you answered “Yes” to any part of question two, please reschedule your appointment. You should self quarantine for at least 14 days.

I certify to the best of my knowledge; this information is accurate.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty: