Virginia Pediatric Group COVID Screening Questionnaire
The purpose of this questionnaire is to obtain health information. The information will be used to ensure the patient is placed in the time slot and location appropriately (in office, curbside/outside tented clinic, telemedicine). Please complete this form only once keeping in mind all who will be attending the appointment.
The protocols we are following due to the pandemic can be reviewed here:
Patient's First Name, Last Name and Date of Birth
In the last 14 days has your child had fevers or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea?
In the last 14 days has your child been exposed to anyone who has/had COVID related symptoms or has/had a positive COVID test and/or is awaiting COVID test results?
In the last 14 days has your child been tested for COVID and has gotten a positive test result and/or is awaiting COVID test results?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service