Online Covid-19 Questionnaire

Patient Name

Age

Who is answering the questions?

Who is answering the questions?(If Other Selected)

1. Do you have a fever or have you felt hot or feverish or had flu-like symptoms at any time in the last two weeks?

2. Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Diarrhea? Fatigue?

3. Have you experienced a recent loss of smell or taste?

4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self isolating because of a determined risk for COVID-19?

5. Have you been recently tested for COVID-19 and are currently waiting for results?

I understand that the current pandemic requires new asepsis and protocols, and additional steps have been taken to further enhance safety of all patients and staff members.

Name Of Person submitting this form

Your Email Address

Date