Covid-19 Patient Questionnaire

Your Name (required)

Your Email (required)

Please read each question and answer YES or NO

Do you/they have fever or have you/they have felt shot or feverish recently (14-21 days?) YESNO

Are you/they having shortness of breath or other difficulties breathing? YESNO

Do you/they have a cough? Or have had a cough in the last 14 days? YESNO

Any other flu like symptoms, such as Gastrointestinal upset, headache, or fatigue in the last 14 days? YESNO

Have you/they experienced recent loss of taste or smell? YESNO

Have you/they had direct contact with any confirmed Covid-19 patients in the last 14 days? Or have been around any individuals with coronavirus symptoms in the last 14 days? YESNO

Do you/they have heart disease, lung disease, kidney disease, diabetes or any autoimmune disorders? YESNO

Have you/they traveled in the past 14 days? YESNO

If so please list where:

Electronic Signature of Patient (or Guardian). By typing your name in the space below you are providing an "electronic signature" and it indicates your approval of the information contained in this electronic form.

Enter today's date:

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