Patient Information
Name
*
Mobile Phone
*
Email
*
Date of Birth
*
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Month
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Day
Year
1
Patient Screening
Do you have heart disease, lung disease, kidney disease, diabetes, asthma, or any auto-immune disorders?
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Yes
No
Do you have any of the following respiratory symptoms?
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Fever
Sore Throat
Cough
Runny Nose
Shortness of Breath or Trouble Breathing
No, I do not have any of these symptoms.
Other
Do you have a fever or have you felt hot or feverish recently (14-21 days)?
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Yes
No
Have you experienced shortness of breath or had trouble breathing?
Yes
No
Do you have a cough?
Yes
No
Do you have a runny nose?
Yes
No
Do you have a sore throat?
Yes
No
Do you currently have any GI symptoms? Are you experiencing flu-like symptoms? (Select all that apply)
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Diarrhea
Nausea
Headache
Fatigue
No, I do not have any of these symptoms.
Other
Are you experiencing flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
Yes
No
Have you experienced a recent loss of taste or smell?
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Yes
No
Have you been in contact with anyone who has tested positive for COVID-19?
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Yes
No
If yes, what date were you last in contact with a person who tested positive?
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Month
/
Day
Year
Date
Have you traveled anywhere by air, bus, or train within the past 14 days?
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Yes
No
If yes, please provide the dates of travel, locations where you traveled, and the transportation method.
*
Have you been tested for COVID-19?
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Yes
No
If yes, what date were you tested?
*
/
Month
/
Day
Year
2
Did you test positive for COVID-19?
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Yes
No
When did you receive results (whether negative or positive)?
*
/
Month
/
Day
Year
3
What date was the onset of your symptoms?
*
/
Month
/
Day
Year
4
Have you been cleared of COVID-19?
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Yes
No
Have you been tested 24 and 48 hours after symptoms are gone?
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Yes
No
What date were you cleared of COVID-19?
*
/
Month
/
Day
Year
5
Is there any additional information you would like to provide?
The following questions pertain to the
COVID-19 Pandemic Notice and Acknowledgment of Risk
.
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I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.
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I understand and accept the increased risk of COVID-19 exposure with treatment at this office.
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I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.
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I have read and understand the information stated above
Signature: By typing your name in the box below, you acknowledge that your answers that you provided are true and accurate to the best of your knowledge. (Please use your mouse to sign if you are using a desktop or laptop.)
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Patient or Legal Representative Name/Relationship
*
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