Patient Pre-Screening Questionnaire Form
Please complete the Patient Pre-Screening Questionnaire Form to help us prepare for your visit. Accurate information ensures efficient and safe care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Reason for Visit
*
Please Select
Routine Checkup
New Symptoms
Follow-up Appointment
Vaccination
Other
Are you currently experiencing any of the following symptoms?
*
Fever or chills
Cough
Shortness of breath
Fatigue
Loss of taste or smell
None of the above
Other
Have you had close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Not Sure
Do you have any allergies?
*
Yes
No
If yes, please specify your allergies
List any chronic health conditions you have (e.g., diabetes, asthma, hypertension)
Submit
Should be Empty: