Pre-Appointment Patient Screening Form

Have you had a fever or above normal temperature within past 14-21 days? YesNo
Have you experienced shortness of breath or had trouble breathing within past 14-21 days? YesNo
Do you have a dry cough? YesNo
Do you have a runny nose? YesNo
Have you recently lost or had a reduction in your sense of smell? YesNo
Do you have a sore throat? YesNo
Have you been in contact with or have a sick family member at home who has tested positive for COVID‐19 within the past 14 days? YesNo
Have you tested positive for COVID‐19? YesNo
Have you been tested for COVID‐19 and are awaiting results? YesNo
Have you traveled outside the United States in the past 14 days? YesNo
Have you traveled within the United States within the past 14 days? YesNo
Do you have any flu-like symptoms? YesNo