COVID-19 Screening Form

Name:

Dr.:

App. Time:

DOB:

Phone Number:

Date:

1) In the past 14 days, have you come in close contact (within 6 feet) with someone who has a laboratory-confirmed COVID-19 diagnosis?

YES NO

2) In the past 14 days, have you had any of the following symptoms:

Cough

YES NO

Shortness of breath or difficulty breathing

YES NO

Fever

YES NO

Chills

YES NO

Muscle Pain

YES NO

Sore Throat

YES NO

New loss of taste or smell

YES NO

Congestion or runny nose

YES NO

Nausea or vomiting

YES NO

Diarrhea

YES NO

If you answered yes to any of these questions, please go wait in your car until we call you.