Covid-19 Screening Questionnaire
Please read each question carefully and note if the answer to any of the questions is Yes. No health information or
questionnaire answers will be shared with anyone.
Have you experienced any of the following symptoms of COVID-19 within the last 48 hours?
Yes No Fever or chills
Yes No Cough
Yes No Shortness of breath or difficulty breathing
Yes No Fatigue
Yes No Muscle or body aches
Yes No Headache
Yes No New loss of taste or smell
Yes No Sore throat
Yes No Congestion or runny nose
Yes No Nausea or vomiting
Yes No Diarrhea
-Have you tested positive for COVID-19 in the past 10 days? Yes No
-Are you currently awaiting results from a COVID-19 test? 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? 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
Please contact me right away and before arrival at your appt if any of your answers from this questionnaire are a Yes.