2021 COVID-19 Questionnaire for Arriving Patients
This survey is intended for any and all patients arriving at our office. Please respond carefully to each question below. Thank you for helping us keep our patients and staff safe during these uncertain times - Lloyd Takao, MD, Pediatrics
Sign in to Google to save your progress. Learn more
Patient Name *
Date of Appointment
Are all the parents and children over 12 years old in your household vaccinated against COVID-19? *
Have you had any close calls or COVID-19 scares in the past 2 weeks? *
Has the patient or any parent had a COVID-test in the last 2 weeks?
Clear selection
Has the patient or any household members been on an airplane, public transit, or BART in the past 2 weeks? *
In the past two weeks, has your child or any household members been with any groups in an enclosed space without a mask? *
Do all the children in your household age 2-12 years wear masks in all enclosed spaces? *
Any questions or concerns?
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy