COVID-19 Patient Screening Form

Have you traveled to any other countries in the last 14 days?
YesNo

Have you traveled to any states outside of your current state in the last 14 days? If yes, Which ones?
YesNo

Has anybody traveled to meet you from any countries or states in the last 14 days?
YesNo

Has anyone you’ve been in contact with, confirmed with the COVID-19 virus in the last 14 days?
YesNo

Has anyone you’ve been in contact with, self-quarantined due to exposure to the COVID-19 virus in the last 14 days?
YesNo

Have you had any of these symptoms in the last 14 days?:

Fever of 99.5 or greater
YesNo

Cough
YesNo

Runny nose not associated with allergies
YesNo

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system. By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Signature: