Pre-Health Screening Questionnaire
Please complete this questionnaire to help us assess your current health status before your appointment or activity.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Screening Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate if you are currently experiencing any of the following symptoms:
*
Rows
No
Yes
Fever or chills
1
2
Cough
3
4
Shortness of breath
5
6
Fatigue
7
8
Loss of taste or smell
9
10
Sore throat
11
12
Headache
13
14
Have you been diagnosed with or treated for any of the following conditions?
*
Rows
No
Yes
Diabetes
15
16
Hypertension
17
18
Heart disease
19
20
Asthma or lung disease
21
22
Immunodeficiency
23
24
Allergies
25
26
Have you traveled internationally in the past 14 days?
*
Yes
No
Have you had close contact with anyone diagnosed with an infectious disease (e.g., COVID-19, flu) in the past 14 days?
*
Yes
No
Are you currently taking any medications? If yes, please list them below.
Is there anything else about your health we should be aware of? (Optional)
Signature (Please sign below to confirm your consent)
*
Submit Screening
Submit Screening
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