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Covid-19 Questionnaire

Please answer the following questions PRIOR to coming to your appointment.  If you are not the patent, please answer for yourself first, then repeat the questionnaire for the patent.

PLEASE DO NOT FILL THIS OUT MORE THAN 24 HOURS BEFORE APPT


These answers are for myselfpick one!
NameYour full name
Patient NameIf different
PhoneYour phone number
Do you have a fever or have you felt hot or feverish recently? (last 14-21 days)pick one!
Are you having shortness of breath or other breathing difficulties?pick one!
Do you have a cough?pick one!
Any other flu-like symptoms such as gastrointestinal upset, headache, or fatigue?pick one!
Have you experienced a recent loss of taste or smell?pick one!
Are you in contact with anyone confirmed COVID-19 positive?pick one!
Are you over 60 years of age?pick one!
Do you have heart/lung/kidney disease, diabetes, or any auto-immune disorders?pick one!
Have you traveled in the past 14 days to any regions affected by COVID-19?pick one!
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