COVID-19 Patient Screen Form
We appreciate your taking the time to complete our COVID screening in advance of your visit to our office. These questions will be repeated on your arrival to ensure nothing has changed since you completed this questionnaire.
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Your full name:
Please check symptoms experienced currently or lately (last 14-21 days)
Difficulty breathing or shortness of breath
Gastrointestinal upset, nausea, vomiting, diarrhea
New loss of taste or smell
Rash or blotchy areas on body
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