Patient COVID-19 Questionnaire Form

Basic Details

Patient Name*

First Last

Today's Date*

Do you have any cold/flu like symptoms?*

Do you have a fever?*

Do you have a cough?*

Do you have a sore throat?*

Have you had loss of taste?*

Have you had diarrhea within the last fourteen days?*

Have you had exposure to any positive case of COVID-19?*

Have you worked in an environment with person(s) having tested positive for COVID-19?*

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*

04/19/2024