COVID-19 Screening
Thank you for completing this screening prior to your appointment.

IF YOU ANSWER "YES" to any of the following questions, please call (518) 288-8431 for further evaluation before coming to the office.

Thank you for wearing a mask at all times in the office.
(Please note that the CDC no longer recommends bandanas, gaiters, or masks with exhaust valves).
Patient name *
1. In the last 14 days, have you experienced any NEW symptoms of illness including: fever or chills, cough, shortness of breath, fatigue, muscle/body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea? *
2. Have you or a household member had a positive COVID-19 test in the past 14 days? *
3. Have you been in close contact with a confirmed or suspected COVID-19 case? *
4. In the past 14 days, have you traveled to or from another state or country for which NY requires a mandated self-quarantine period? *
5. In the past 14 days, while gathering indoors with non-household/ non-pod members, have you been without your face mask? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy