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COVID-19 Screening Tool
We respectfully ask that you disclose if: you, or someone you have been in close contact with in the past 2 weeks, has or has had: (check any that apply)
None of these
Fever of 100.4° F [38.0° C] or greater (without the use of fever-reducing or other symptom-altering medicines (e.g. cough suppressants)).
Chills
Cough (non-asthmatic)
Shortness of breath or difficulty breathing (non-asthmatic)
Fatigue
New muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
In the two weeks before your appointment, have you:
*
Yes
No
Received a positive COVID-19 test result or suspect you have COVID-19?
Yes
No
Had contact with someone diagnosed with COVID-19?
Yes
No
Traveled outside the country in or to a place where COVID-19 is currently a hotspot?
Yes
No
Cared for someone who is ill or has been ill?
Yes
No
Contact Information
First Name
Last Name
Phone
Email Address
*
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