EmailMe Form - COVID-19 Screening Survey

Name of Patient being Treated *

First Last

1. Are you immunocompromised and/or live in a highest-risk congregate care setting? *

Yes

No

2. Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions.

• Fever and/or chills
• Cough or barking cough
• Shortness of breath
• Decrease or loss of taste or smell
• Muscle aches/joint pain
• Extreme tiredness
• Sore throat
• Runny or stuffy/congested nose
• Headache
• Nausea, vomiting and/or diarrhea
• Abdominal pain
• Pink eye

Select “No” if all of these apply:
• you do not have a fever, and
• your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea). *

Yes

No

3. Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home? *

Yes

No

4. In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit? *

Yes

No

I, verify that the answers I provided on this form to be truthful and honest. It is my responsibility to notify the office if any of the answer changes before my appointment. *

Yes

No

Updated Changes in Our Office:

1. You are no longer required to wear a mask when you enter the office.

2. When you arrive, you no longer have to call our office and wait in the car. You are welcome to come inside and check-in.

3. You will be asked to use hand sanitizer when you enter and exit the office.

4. We will ask some screening questions again, related to COVID-19 when you enter the office.