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Covid-19 Pre-Check Questionnaire
This form must be filled out prior to being seen
Email *
Patient First Name *
Patient Last Name *
Phone number (including area code) *
Have you/patient tested positive for COVID-19? *
If you/patient tested positive for COVID-19, when were you/patient tested?
Have you/patient been tested for COVID-19 and are awaiting results? *
Have you/patient traveled to high-risk areas in the past 14 days? *
Have you/patient been in contact with someone who has tested positive for COVID-19 within the last 14 days? *
Have you/patient experienced shortness of breath or had trouble breathing? *
Do you/patient have a cough, runny nose, sore throat, loss of taste or smell, chills, shaking, or muscle pain? *
Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue, or otherwise feel unwell? *
Have you/patient taken any fever-reducing medications, including: ibuprofen (Advil, Motrin or other), acetaminophen (Tylenol or other), naproxen (Aleve or other) or aspirin in the last 14 days and, if yes, for what reason? *
If you answered yes to taking fever reducing medication please provide a reason why below.
Do you/patient have a fever or above normal temperature? *
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