Patient COVID-19 Questionnaire Form Basic DetailsPatient 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* Reset signature Signature locked. Reset to sign again 03/26/2023
