Covid-19 Health Check-In Little Bean Lactation in office visits Question Title * 1. What is your FIRST and LAST name? First Name Last Name OK Question Title * 2. What date and time is your in office appointment? Date / Time Date Time AM/PM - AM PM OK 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? Yes No OK 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) Yes No OK 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? Yes No OK 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. Yes No OK DONE