Health Screening Form

1

If you have been exposed to a communicable disease, you may spread the disease to your provider, administrative staff, and/or other clients in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission. Responses will be kept confidential and will be reviewed by your provider/MPG Staff who will provide guidance regarding any adjustments to your scheduled appointment.

2

Your Name* This field is required.

First Name

Last Name

3

Email* This field is required.

example@example.com

4

Phone Number:* This field is required.

5

Have you, anyone in your household, or others accompanying you today had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100.4° F? ** This field is required.

Yes

No

6

Please check symptoms below* This field is required.You or anyone in your household has had within the past 21 days.

Sore Throat

Cough

Chills

Body Aches

Shortness of Breath

Fever at or greater than 100.4° F

Loss of Smell

Loss of Taste

7

Have you or anyone in your household been tested for COVID-19?* This field is required.

Yes

No

8

Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?* This field is required.

Yes

No

9

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19? * This field is required.

Yes

No

10

To the best of your knowledge, have you been in close proximity to any individual who tested positive for COVID-19?* This field is required.

Yes

No

11

Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?* This field is required.

Yes

No

12

Have you or anyone in your household traveled in the past 21 days?* This field is required.

Yes

No

13

Although exposure is unlikely, do you accept the risk and consent to treatment?* This field is required.

Yes

No

14

I confirm that the information given in this form is completed, true and accurate to the best of my knowledge.* This field is required.

I Confirm

15

I understand that if the answer to any of these questions is yes, I may be asked further questions to clarify my situation and reschedule today’s appointment to a later date. * This field is required.

I Understand

16

By selecting the "I Accept" button, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.* This field is required.

I Accept