COVID-19 Screening Questionnaire

Our office policy as of 9/10/2020 is that any individual tested positive for COVID-19 must have (1) negative COVID test following their initial positive COVID test before being seen by the doctor.

Please wear a mask to your appointment. Our office currently takes temperature before being taken into an exam room. If you have any questions or concerns on your safety during your visit, please call our office at 240-641-8735.

Patient Information

First name

Last name

Appointment Information

You must complete this COVID-19 screening questionnaire before each visit to our office. Please confirm today's date and the date of your appointment.

Today's date

Date of your appointment

Symptom History

Have you experienced any of the following symptoms in the past 14 days?

Fever more than 100.4*F?

Yes No

Shortness of breath or difficulty breathing

Yes No

Dry cough?

Yes No

Loss or reduction in sense of smell or taste?

Yes No

Sore throat?

Yes No

Chills or repeated shaking with chills?

Yes No

Headache?

Yes No

Diarrhea?

Yes No

Have you had any of the above mentioned symptoms in the last 14 days?

Yes No

Contact History

In the past 14 days have you had close contact with anyone who has tested positive for COVID-19?

Yes No

Have you been tested for COVID-19 in the past 14 days?

Yes No

Were you tested for COVID-19, were you tested because of symptoms or exposure?

Yes No

ONLY IF YOU WERE TESTED: What is the result of your COVID-19 test(s)?

Positive

Our office policy requires you to have (1) negative COVID result following a positive result to be seen by the doctor.

Negative I have not received the results yet

Please complete this questionnaire again if any of your answers change before your appointment.

I agree to notify the practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand that if I do not provide the whole truth when completing this form or I am misleading in any way, I will be dismissed from the practice.

To the best of our knowledge, Chevy Chase Foot & Ankle LLC staff are symptom-free at the time of your visit. However, since we are a place of healthcare services, other persons (including other patients) could be infected, with or without their/our knowledge.

While our office complies with Federal, State Health Department, and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees about your health and safety.

I hereby acknowledge and understand that there may be an increased risk that COVID-19 may be transmitted in any place of public accommodation, which includes my physician’s office. I have been informed by my physician of their desire to protect their patients, staff, and the community at large.

Please Type Your Name Below (this acts as an e-signature)

Your information will be encrypted.

COVID-19 Screening Questionnaire

Our office policy as of 9/10/2020 is that any individual tested positive for COVID-19 must have (1) negative COVID test following their initial positive COVID test before being seen by the doctor.

Patient Information

Appointment Information

Symptom History

Contact History

Please complete this questionnaire again if any of your answers change before your appointment.

Our office policy as of 9/10/2020 is that any individual tested positive for COVID-19 must have (1) negative COVID test following their initial positive COVID test before being seen by the doctor.

Chevy Chase Foot and Ankle LLC