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Patient COVID-19 Questionnaire Form
"
*
" indicates required fields
Basic Details
Patient Name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
Do you have any cold/flu like symptoms?
*
Yes
No
Do you have a fever?
*
Yes
No
Do you have a cough?
*
Yes
No
Do you have a sore throat?
*
Yes
No
Have you had loss of taste?
*
Yes
No
Have you had diarrhea within the last fourteen days?
*
Yes
No
Have you had exposure to any positive case of COVID-19?
*
Yes
No
Have you worked in an environment with person(s) having tested positive for COVID-19?
*
Yes
No
Terms & Conditions
I certify that I have read and understand the above information. To the best knowledge, the above questions have been accurately answered. I withholding information can be dangerous to the health of the community at large.
Signature
*
05/09/2025
