Screening for Symptoms of COVID-19 Before Your Office Visit

Please complete this form 24 to 48 hours before your appointment. If there is any change in your situation or symptoms in the mean time, please let us know. (These questions apply to the person being seen and in the case of a child, the child and the parent that will be coming in with them.)

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* 1. Please enter you or your child's first name and last initial.

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* 2. Please enter your appointment date and time.

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* 3. Have you or your child traveled out of the area in the last 14 days?

Yes

If yes, when and where was your travel?

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* 4. Have you or your child had contact with anyone with confirmed or suspected COVID-19 in the last 14 days?

Yes

If yes, please provide details.

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* 5. Have you or your child had any of these symptoms in the last 14 days? Please only include symptoms that are new for you or worsening in the last two weeks.

Fever greater than 100

New or worsening cough

Difficulty breathing

Chills or shakes

Whole body aches or muscle pain

Headache

Sore throat

New loss of sense of smell or taste

Vomiting or diarrhea

Generally feeling ill

None of the above

Please provide any details needed.