Covid-19 Health Check-In

Little Bean Lactation OFFICE VISIT SCREENING

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* 1. What is your FIRST and LAST name?

First Name

Last Name

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

Date / Time

Date

Time

AM/PM

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* 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

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* 4. In the past 10 days, have you tested positive for COVID-19 using a rapid or PCR nasal swab?

Yes

No

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* 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 were actively contagious?

Yes

No

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* 6. Have you been fully vaccinated against the COVID-19 virus?

Yes

No

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* 7. If you are fully vaccinated, which vaccine did you receive?