COVID-19 Screening Questionnaire

Please correct the errors described below.

In the last two weeks, have you had any of the following symptoms: (For the following questions, please choose either yes or no. )

1. Fever (measured over 100.2 degrees Fahrenheit)

Yes No

2. Cough (worse than baseline)

Yes No

3. Shortness of breath or difficulty breathing (worse than baseline)

Yes No

4. Nausea or vomiting

Yes No

5. Diarrhea

Yes No

6. Sore throat

Yes No

7. New loss of taste or smell

Yes No

8. In the last two weeks, have you had personal contact with someone known to be infected with COVID-19?

Yes No

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.

Patient's Name / Signature

Date

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SouthDenver ENT & Allergy

Phone: (303) 953-6767, Fax: (303) 953-7694
www.araoent.com
276040612548816
SouthDenverENT
15 W Dry Creek Circle, , Littleton, CO, 80120, US

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