COVID-19 Screening Questionnaire

Our families, staff, and community mean a great deal to us, and your safety is our top priority! During the COVID -19 pandemic, we have instituted a screening process. Please complete this questionnaire prior to entry into our office.

Your responses will be kept confidential and will be reviewed by a practicing clinician who will provide guidance regarding any adjustments to the patient’s scheduled appointment.

1. Have you or anyone in your household had any of the following symptoms in the last 21 days: (If yes, Please check all the boxes that apply)?

Cough   Yes  No
Chills   Yes  No
Fever at or greater than 100 degrees Fahrenheit   Yes  No
Shortness of breath/difficulty breathing   Yes  No
Muscle or body aches   Yes  No
Sore throat   Yes  No

New loss of taste or smell Diarrhea   Yes  No
Headache   Yes  No
Nausea or vomiting   Yes  No
New fatigue   Yes  No
Congestion or runny nose   Yes  No

2. Have you or anyone in your household tested POSITIVE for COVID-19?
 Yes  No

3. Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19 in the past 21 days?
 Yes  No

4. To the best of your knowledge have you been in CLOSE PHYSICAL CONTACT to any individual who tested positive for COVID-19 in the past 21 days?
 Yes  No

DOB: 

Signature of Patient or Guardian