COVID-19 Screening Survey Name * First Name Last Name Birthday * MM DD YYYY Have you experienced any of the following symptoms in the past 48 hours: * • fever 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 • diarrhea Yes No Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with: * • Anyone who is known to have laboratory-confirmed COVID-19? OR • Anyone who has any symptoms consistent with COVID-19? Yes No Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? * Yes No Are you currently waiting on the results of a COVID-19 test? * Yes No Thank you! if you answered yes to any question, you would have to reschedule your appointment
