COVID-19 Questionnaire
Patient's Name
*
Parent/Guardian Name
Patient/Guardian Email
*
example@example.com
Do you have a fever or have you experienced a fever within the past 14 days?
*
Yes
No
Have you experienced a recent onset of respiratory problems, such as a cough or difficulty in breathing within the past 14 days?
*
Yes
No
Have you, within the past 14 days, traveled outside the country?
*
Yes
No
Have you been out of the state of Pennsylvania in the last 14 days?
*
Yes
No
Please list the states visited
*
Have you come into contact with a person with confirmed COVID-19 infection within the past 14 days?
*
Yes
No
Have you come into contact with people from confirmed cities,surrounding areas or people from a neighborhood with recent documented fever or respiratory problems within 14 days?
*
Yes
No
Patient/Parent's Signature
*
Use your mouse or finger to draw your signature above
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: