Healthcare COVID-19 Screening Questionnaire
Please complete the Healthcare COVID-19 Screening Questionnaire to help us ensure a safe environment for all visitors and patients.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Screening
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any of the following symptoms in the last 14 days? (Fever, cough, shortness of breath, loss of taste or smell, sore throat, muscle aches, chills, headache, or fatigue)
*
Fever
Cough
Shortness of breath
Loss of taste or smell
Sore throat
Muscle aches
Chills
Headache
Fatigue
None of the above
Have you had close contact with anyone diagnosed with COVID-19 in the past 14 days?
*
Yes
No
Not sure
Have you traveled internationally or to a COVID-19 high-risk area in the last 14 days?
*
Yes
No
Have you received a COVID-19 vaccine?
*
Yes, fully vaccinated
Yes, partially vaccinated
No
Have you tested positive for COVID-19 in the past 14 days?
*
Yes
No
Are you currently awaiting results of a COVID-19 test?
*
Yes
No
Submit Screening
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