COVID-19 Infectious Disease Screening

The purpose of this screening questionnaire is to screen for potentially contagious COVID-19 and to protect patients as well as staff.

All patients must be wearing a mask when entering the clinical area/office.

Have you or anyone in your household been diagnosed with COVID-19 in the past 14 days?

Yes No

Have you or anyone in your household been tested for COVID-19?

Yes No

Have you been tested for COVID-19?

Yes No

Results

Positive Negative

Date Tested

Have you received two doses of the COVID-19 vaccine?

Yes No

Dose 1 Date

Dose 2 Date

Which vaccine did you receive?

Moderna Pfizer J and J

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?

Yes No

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?

Yes No

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?

Yes No

2. Do you have symptoms concerning COVID-19?

Yes No

If YES, when did the symptoms start?

Do you have a fever at or greater than 100 degrees Fahrenheit and/or chills?

Yes No

Do you have a cough?

Yes No

Do you have shortness of breath?

Yes No

Do you have a sore throat?

Yes No

Do you have body/muscle aches?

Yes No

Do you have a new loss of taste or smell?

Yes No

Do you have loss of appetite/poor feeding?

Yes No

Are you vomiting?

Yes No

Do you have diarrhea?

Yes No

Do you have a headache?

Yes No

Do you have a runny nose?

Yes No

Do you have abdominal pain?

Yes No

Do you have a rash? (Rash in a patient under 21 years of age may indicate COVID-19)

Yes No

3. Have you had close contact with a person with COVID-19 in the past 14 days?

Yes No

4. Have you or anyone in your household traveled IN OR OUT of the U.S. in the past 21 days?

Yes No

If YES, where did you travel to?

If YES, what was the date of departure and date of return to NY?

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/Legal Guardian

Date

Your information will be encrypted.