COVID-19 Questionnaire COVID -19 Name First Last Date Date Format: MM slash DD slash YYYY Email In the past 30 days, have you travelled outside the US?*YesNoIn the past 30 days, have you been in contact with a person who has tested positive for COVID-19?*YesNoIn the last 48 hours, have you had a fever (100.4+)?*YesNoIn the last 48 hours, have you experienced any coughing?*YesNoIn the last 48 hours, have you had a sore throat?*YesNoIn the last 48 hours, have you had difficulty breathing?*YesNoIn the last 48 hours, have you had muscle aches?*YesNoIn the last 48 hours, have you had stomach pain?*YesNoHealth Information Protection* I acknowledge that I have read the office's Notice of Privacy Practices Patient Signature
