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WELLNESS QUESTIONNAIRE
Wellness Questionnaire Please fill out for each patient and appointment.
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* Indicates required question
Email
*
Your email
Name of Patient(s)
*
Your answer
Appointment Date
*
MM
/
DD
/
YYYY
Does your child or any close contacts have any of the following symptoms ?
*
Fever
Cough
Congestion, Runny Nose
Sore Throat
Chills
Body Aches/Muscle Aches
Headache
Poor appetite or poor feeding, especially in babies under 1 year old
Nausea or vomiting/Diarrhea
None of the Above
Required
If yes, when did these symptoms begin ?
Your answer
Have you or any members of your household or close contacts been exposed to someone being tested for COVID 19 or other illnesses in the last 5 days?
*
YES
NO
If yes, explain
Your answer
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