Little Bean Lactation in office visits

Question Title

* 1. What is your FIRST and LAST name?

Question Title

* 2. What date and time is your in office appointment?

Date
Time

Question Title

* 3. Have you experienced a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell, or shortness of breath within the past 10 days?

Question Title

* 4. In the past 10 days, have you tested positive for COVID-19 using a test that tested saliva or used a nose or throat swab (not a blood test)? (10 days measured from the date you were tested, not the date you received the test results)

Question Title

* 5. To the best of your knowledge, in the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone while they had COVID?

Question Title

* 6. In the past 14 days, have you traveled internationally or returned from a state identified by New Jersey as having widespread community transmission of COVID-19 (other than just passing through the restricted state for less than 24 hours)?   Visit https://coronavirus.health.ny.gov/covid-19-travel-advisory for applicable states.

0 of 6 answered
 

T