Please read each question carefully and note if the answer to any of the questions is Yes.
No health information or questionnaire answers will be shared with anyone.
Have you experienced any of the following symptoms of COVID-19 within the last 48 hours?
- Yes No Fever or chills
- Yes No Cough
- Yes No Shortness of breath or difficulty breathing
- Yes No Fatigue
- Yes No Muscle or body aches
- Yes No Headache
- Yes No New loss of taste or smell
- Yes No Sore throat
- Yes No Congestion or runny nose
- Yes No Nausea or vomiting
- Yes No Diarrhea
- Have you tested positive for COVID-19 in the past 10 days? Yes No
- Are you currently awaiting results from a COVID-19 test? Yes No
- Have you been diagnosed with COVID-19 by a licensed healthcare provider (for example, a doctor, nurse, pharmacist, or other) in the
past 10 days? Yes No - Have you been told that you are suspected to have COVID-19 by a licensed healthcare provider in the past 10 days? Yes No
Please contact me right away and before arrival at your appt if any of your answers from this questionnaire are a Yes.