Wellness Screening Form
Please complete this form WHEN YOU ARRIVE FOR YOUR APPOINTMENT. Complete one form for each patient to be seen today. If you feel that an adult must accompany the patient into the office, complete one form for the adult companion as well. Dr. Casaus will review your responses and contact you for clarification if needed. You will receive a text when we are ready for you to enter the office. Please keep the air conditioner in your car on while you wait. Thank you!
First and Last Name: *
Your answer
Date of Birth: *
Your answer
Cell phone number where you can be reached right now: *
Your answer
Have you been tested for COVID-19? *
Required
Do you have a fever or have you felt hot or feverish in the past three weeks? *
Required
Are you having shortness of breath or other difficulty breathing? *
Required
Do you have a cough? *
Required
Do you have any other flu-like symptoms such as gastrointestinal upset, headache, or fatigue? *
Required
Have you experienced recent loss of taste or smell? *
Required
Have you been in contact with any confirmed COVID-19 positive patients? *
Required
Is your age over 60? *
Required
Do you have heart disease, lung disease, kidney disease, diabetes, autoimmune disease, or immune suppression? *
Required
Have you traveled in the past 14 days to any regions heavily impacted by COVID-19? *
Required
Have you traveled outside of New Mexico in the past 14 days? *
Required
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