COVID-19 Screening

We are pleased to welcome you to our office. Please take a few minutes to fill out as completely as you can. If you have any questions we will be glad to help you.
Last Name
First Name
Birthdate
Have you been diagnosed with coronavirus (COVID-19)?
Do you have fever or had fever recently (14-21 days)?
Are you having shortness of breath or other difficulties breathing?
Do you have a cough, or have you had a cough within the last 48 hours?
Have you had flu like symptoms or gastrointestinal upset within the last 48 hours?
Have you experienced recent loss of taste or smell?
Have you had close contact with an individual diagnosed with COVID-19?
Is your age over 60?
Do you have heart disease, lung disease or kidney disease or diabetes?
Have you travelled to a country designated as Level 2 or 3 by the CDC?