Pediatric Office COVID Screening Form

(CARE CENTER) COVID-19 SCREENING QUESTIONNAIRE
In order to confirm your appointment at (CARE CENTER), we kindly ask that you complete the following.

Please select and answer to each question*

	Yes	No
Has the patient or anyone in the household tested positive for COVID-19 or awaiting results?
Has the patient or anyone in the household been tested for COVID-19 and are awaiting results?
Does the patient or anyone in the household have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Congestion, Shortness of Breath?
Has the patient or anyone in the household been in contact with someone who has tested positive for COVID-19 in the last 14 days?
Has the patient or anyone in the household traveled within the United States by air, bus or train within the past 14 days?