COVID-19 Screening Questionnaire

You must complete this screening questionnaire before each appointment

Please correct the errors described below.

Client Information

First name

Last name

Email address

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

Contact History

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

Yes No

In the past 14 days have you had close contact with anyone who has travelled to any other states or any other country?

Yes No

Travel History

In the past 14 days have you visited any other states?

Yes No

If yes, list every state you have visited in the past 14 days

In the past 14 days have you visited any other countries?

Yes No

If yes, list every country you have visited in the past 14 days

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

Your information will be encrypted.

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