COVID-19 Screening Questionnaire

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Patient Name:

Person filling out the form:

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COVID-19 Screening Questionnaire

Our families, staff and community mean a great deal to us and your safety is our top priority! During the COVID-19 pandemic, we have instituted a screening process. Please complete this questionnaire prior to entry into our office.

Your responses will be kept confidential and will be reviewed by a practice clinician who will provide guidance regarding any adjustments to the patient’s scheduled appointment.

1. Have you or anyone in your house hold had any of the following symptoms in the last 2 days (If yes, please check all the boxes that apply)

Cough

Fever at or greater than 100 degrees Fahrenheit

Chills

Shortness of breath/difficulty breathing

Muscle or body aches

Sore throat

New loss of taste or smell,

Diarrhea

Headache

Nausea or vomiting

New fatigue

Congestion or runny nose

2. Have you or anyone in your household tested POSITIVE for COVID-19?

Yes No

If yes, when?

3. Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested POSITVE for COVID-19 in the past 21 days?

Yes No

If yes, when?

4. To the best of your knowledge have you been in CLOSE PHYSICAL CONTACT to any individual who tested positive for COVID-19 in the past 21 days?

Yes No

If yes, when?

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