COVID Screening Questionnaire & Protocol

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this questionnaire 1 day prior to your child's in-person appointment. In the interest of safety for our clients, staff, and their families, you may be asked to reschedule if any positive answers are provided to this questionnaire. The policy of our building is to have all who enter wear masks at all times while in the building's common areas and offices. All clients will be required to wash their hands or use hand sanitizer to disinfect hands thoroughly when they arrive. We ask that children come with only one adult, to decrease numbers in our reception area. While a parent or guardian must remain on the premises for the duration of your child's appointment, please feel free to wait in your car if that is more comfortable for you. Please do not plan to come early to your scheduled appointment, but instead wait in your car until your scheduled appointment time. All common touchpoints such as door handles, counters, chair arms, etc. will be disinfected frequently. Lastly, we ask clients to contact our office if they experience COVID-19 symptoms within 14 days after their appointment.

Client's Full Name: *

Date of Appointment: *

YYYY

Scheduled Appointment Time: *

Time

Parent/Guardian Cell Phone Number: *

Have you or anyone in your family tested positive for COVID-19 within the last 30 days? *

Yes

Have you been tested for COVID-19 and are awaiting results? *

Yes

Have you been in close contact with a confirmed case of COVID-19 in the last fourteen days? *

Yes

Have you been fully vaccinated with a COVID-19 vaccine (both shots if applicable)? *

Yes

Received only 1 of 2 doses

Prefer not to say

Have you traveled by air, bus, or train within the last 14 days?. *

Yes

Have you had a fever of 100.4 or higher within the last 48 hours? *

Yes

Have you experienced any of the following symptoms in the last 14-21 days? *

shortness of breath or other difficulty breathing

cough

sore throat

GI issues (vomiting, diarrhea, stomach pain)

flu-like symptoms (e.g., headache, fatigue)

recent loss of taste or smell

I have not experienced any of the above symptoms.

Required

Parent/Guardian: By electronically signing this document, I acknowledge that the answers I have provided above are true and accurate. *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of A.L.L. Diagnostics & Consulting LLC.

Does this form look suspicious? Report

Forms