Covid-19 (CoronaVirus) Questionnaire

To prevent the spread of COVID-19 and reduce the potential risk of exposure, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.

Date

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

1. Have you returned from any of the countries listed on Coronavirus website within the last 30 days? https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html

2. Have you been in close contact with anyone who has traveled within the last 30 days to one of the countries listed on the CDC website? https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html

3. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 30 days

4. Have you experienced any cold or flu-like symptoms in the last 30 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?

5. By checking YES below, I do consent to having my temperature taken and understand that if my temperature is over 99* I will need to reschedule my appointment. I understand that if I check NO to consent that my appointment will be cancelled

For everyone's safety, If you answered "yes” to any of the questions (except #5) you will be to contacted to reschedule your appointment. Thank you for your understanding.

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