1. Do you have a fever or abovenormal temperature (>100.4°F)? Take temperature at appointment
2. Are you experiencing shortness of breath or having trouble breathing?
3. Do you have a dry cough?
4. Do you have a runny nose?
5. Have you recently lost or had a reduction in your sense of smell sor taste?
6. Do you have a sore throat?
7. Are you experiencing chills or repeated shaking with chills?
8. Do you have unexplained muscle pain?
9. Do you have a headache?
10. Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
11. Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
12. Have you been tested for COVID-19 in the last 14 days? If “no,” proceed to next question
If yes, what is the result of the
If negative, proceed to next
If still waiting on results, schedule
appointment after results are
13. Have you traveled more than 100 miles from your home in the last 14 days?
If yes, than where:
Patient signature at appointment: