COVID-19 Screening Questionnaire

Please correct the errors described below.

Client Information

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.

Symptom History

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

Vaccination Status

Contact History

Travel History

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

If you have responded yes to any of the above questions, other than regarding your vaccine status, please contact our office by telephone to discuss the appropriate next steps.

Your information will be encrypted.