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?

Contact History

Travel History

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

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