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COVID 19 pre-screening questionnaire
COVID19 screening at visit (***MASKS are required in our clinic)
Follow up Questionnaire
New Patient Form
New Patient Pain Questionnaire
COVID19 screening at visit (***MASKS are required in our clinic)
Last Name
*
First name
*
Have you been vaccinated for COVID19?
*
Yes
No
Have you experienced any of the following symptoms of COVID-19 within the last 72 hours: *Fevers or Chills?
*
Yes
No
Cough?
*
Yes
No
Difficulty breathing or Short of breath?
*
Yes
No
Fatigue?
*
Yes
No
Muscle or Body ache?
*
Yes
No
Headache?
Yes
No
New lost of taste or smell?
Yes
No
Sore Throat?
*
Yes
No
Stuffy nose or runny nose?
*
Yes
No
Nausea or Vomiting?
*
Yes
No
Diarrhea?
*
Yes
No
Have you tested positive for COVID-19 in the past 14 days?
*
-- Please Select --
Yes
No
Are you currently awaiting results from a COVID-19 test?
*
-- Please Select --
Yes
No
Have you been diagnosed with COVID-19 by a licensed healthcare provider (for example, a doctor, nurse, pharmacist, or other) in the past 10 days?
*
-- Please Select --
Yes
No
Have you been told that you are suspected to have COVID-19 by a licensed healthcare provider in the past 10 days? Yes No Yes No Yes No
-- Please Select --
Yes
No
***Please note that Masks are required in our clinic.
* Required field
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