COVID-19 Questionnaire COVID -19 Name First Last Date MM slash DD slash YYYY Email In the past 30 days, have you travelled outside the US?* Yes No In the past 30 days, have you been in contact with a person who has tested positive for COVID-19?* Yes No In the last 48 hours, have you had a fever (100.4+)?* Yes No In the last 48 hours, have you experienced any coughing?* Yes No In the last 48 hours, have you had a sore throat?* Yes No In the last 48 hours, have you had difficulty breathing?* Yes No In the last 48 hours, have you had muscle aches?* Yes No In the last 48 hours, have you had stomach pain?* Yes No Health Information Protection* I acknowledge that I have read the office's Notice of Privacy Practices Patient Signature
