Pre-Appointment Wellness Form
COVID-19
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Patient Date of Appointment
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
2
Have you ever tested positive for COVID-19?
*
Yes
No
Do you reside in a nursing home, senior living center, or other type of group home?
*
Yes
No
Is your age over 60?
*
Yes
No
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
*
Yes
No
Please state whether you have any of the following medical conditions.
*
Rows
Yes
No
Heart Disease
3
4
Lung Disease
5
6
Kidney Disease
7
8
Diabetes
9
10
Auto-immune Disorders
11
12
Please state whether you have experienced the following symptoms in the past 14-21 days, please select them below.
*
Rows
Yes
No
Fever, Feverish, or Felt Hot
13
14
Shortness of Breath or Difficulties Breathing
15
16
Cough
17
18
Flu-like Symptoms (gastrointestinal upset, headache, or fatigue)
19
20
Loss of Taste or Smell
21
22
Have you been in close contact with anyone with a cough, fever, shortness of breath, or COVID-19 in the past 14-21 days?
*
Yes
No
Patient or Parent/Guardian Signature
*
Submit
Should be Empty: