COVID-19 Screening Questionnaire

Appointment Information

COVID-19 Screening questionnaire must be submitted prior to appointment. Remember wearing a mask to your appointment is required and only patients are allowed in clinic.

Client Information

First name

Last name

Date of Birth

Phone number

Appointment Information

You must complete this COVID-19 screening questionnaire before each visit to our office on the day of your visit. 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 or chills

Yes No

Cough

Yes No

Shortness of breath or difficulty breathing

Yes No

Fatigue

Yes No

Muscle or body aches

Yes No

Headache

Yes No

New loss of taste or smell

Yes No

Sore throat

Yes No

Congestion or runny nose

Yes No

Nausea or vomiting

Yes No

Diarrhea

Yes No

If you answered YES to any COVID symptom questions please DO NOT enter the building; instead, call our office at 901-747-2229 to reschedule your appointment. Please contact your primary care physician for further guidance.
If you answered NO to all, proceed to the next question.

Contact History

In the past 14 days has a member of your household been diagnosed with COVID-19 or suspected to have COVID-19?

Yes No

If you answered yes, please contact our office at 901-747-2229 and reschedule your appointment.

In the past 14 days have you been in close contact with anyone diagnosed with COVID-19 or suspected to have COVID-19?

Yes No

Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?

Yes No

If you answered yes, please contact our office at 901-747-2229 and reschedule your appointment.

Are you currently waiting on the results of a COVID-19 test?

Yes No

If you answered yes, please contact our office at 901-747-2229 and reschedule your appointment.

REMINDER: Only patients with appointments are allowed clinic entry. NO Patient Partners or Visitors are allowed clinic entry at this time. Anyone entering the building and clinic is required to wear a facemask. Please remember to social distance and hand wash or hand sanitize frequently when visiting our office.

Fertility Associates of Memphis is committed to helping slow the spread of COVID-19 and is following all recommendations provided by local, state, and national authorities.
Thank you for your support!

Patient Signature

Date

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