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?	1	2
Has the patient or anyone in the household been tested for COVID-19 and are awaiting results?	3	4
Does the patient or anyone in the household have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Congestion, Shortness of Breath?	5	6
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?	7	8
Has the patient or anyone in the household traveled within the United States by air, bus or train within the past 14 days?	9	10