COVID-19 Questionnaire

First Name:

Last Name:

Please answer the questions below to the best of your knowledge.

1. Do you have or have you had any of the following symptoms in the last 10 days? Loss of taste or smell, cough, fever of 100.3 or above, shortness of breath, flu like symptoms, gastrointestinal upset?

Yes

If yes, please enter the symptom(s) that apply to you:

If your answer is yes, please provide the date of your positive test(s):

Additional positive test date (if needed):

If yes, please provide the date of your exposure to the COVID-19 positive person:

Would you like to add any comments?

If yes, please comment here:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient / Parent / Guardian

Date

Your information will be encrypted.