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COVID 19 - Screening - 202201
Personal Info
First Name
Last Name
Contact Info
Email
COVID Questions
Symptoms: Do you have any of the following?
Fever / Headache / Difficulty Swallowing / Sore Throat / New Cough / Cough Worsening / Difficulty Breathing / Persistent Chest Pain / Loss of Taste or Smell / Muscle Aches / Fatigue / Chills.
Yes
No
Pink Eye / Nasal or Sinus Congestion / Nausea / Diarrhea / Vomiting / Pink Eye / Nasal or Sinus Congestion / Abdominal Pain / Sudden Onset of Body Pain / New Rash or Other Skin Changes.
Yes
No
If a child, are they experiencing purple markings on fingers and toes?
Yes
No
Screening
Have you had any changes to your medical history since the initial intake?
Yes
No
Are your willing to wash hands before entering clinic?
Yes
No
Are you willing to wear face mask in the clinic and during treatment??
Yes
No
Have you tested positive for COVID-19 in the last month?
Yes
No
Have you been in contact with anyone with COVID-19 or had close contact with a confirmed case of COVID-19?
Yes
No
Have you been around anyone with cold-like symptoms?
Yes
No
Travel
Have you travelled recently outside the country or been on an airplane?
Yes
No
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