COVID-19 Patient Form

COVID Health Questionnaire Form

Today's Date*

Patient's Name*

First Last

Phone*

Email*

Have you or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?*

Yes
No

If yes, when?*

Do you or others accompanying you to today’s appointment or other recent acquaintances have any of the following symptoms:

Fever (defined as above 99.6 degrees)?*

Yes
No

Cough?*

Yes
No

Shortness of breath and/or trouble breathing?*

Yes
No

Persistent pain, pressure, or tightness in the chest?*

Yes
No

Other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*

Yes
No

Recent loss of taste or smell?*

Yes
No

Have you/they traveled in the past 14 days to any regions affected by COVID-19?*

Yes
No

Any heart disease, kidney disease, diabetes, or autoimmune disorders?*

Yes
No

Consent*

I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s appointment.*

First and Last Name of person who completed this form*

First Last

Signature as acknowledgment of Covid Health Questionnaire*

COVID Health Questionnaire Form

Consent for Care Form

Section 1 (For New Patients only)

Section 2 (For All Patients)