Covid 19 Questionnaire

1. Are you experiencing ANY of the following emergency symptoms: severe shortness of breath and difficulty breathing, persistent chest pain or pressure, new confusion or inability to arouse, bluish lips or face, loss of consciousness, slurred speech, arid/or severe, constant dizziness or lightheadedness? *

Y

N

2. Are you experiencing any of the following symptoms? Please select all that apply. *

3. Have you been told by a health official that you may have been exposed to COVID-19 (coronavirus)? *

Y

N

4. Have you been around someone who is known to have COVID-19 (coronavirus}? *

Y

N

5. Have you been tested before for COVID-19? *

Y

N

6. How many people do you currently live with? *

0 - I live alone

1

2

3+

7. In the last 14 days, have you been in an area of high-risk for COVID-19 (coronavirus)? *

Y	N
I don't know

8. In the last 14 days, have you traveled internationally? *

Y

N

9. In the last 14 days, have you traveled on a cruise ship? *

Y

N

10. In the last 14 days, have you been around someone who recently traveled to a high-risk area and is also sick? *

Y

N

11. Do you live or work in a care facility? (This includes a hospital, emergency room, other medical setting, or long-term facility.) *

Y

N

12. Are you currently working in an industry providing critical services that require you to work on location? (This includes industries such as grocery, banking, childcare, etc.) *

Y

N

13. Over the last 14 days, have you and the people you live with been practicing social distancing of 6 feet or more? *

Y

N

14. Over the last 14 days, have you or the people you live with congregated with groups of more than 10 people? *

Y

N

15. COVID-19 (coronavirus) affects various ages differently. How old are you? *

16. Do you have any of the following? Please select all that apply. *

17. COVID-19 (coronavirus) can affect people who have weaker immune systems from things like chemotherapy, HIV/AIDS, organ transplant, being pregnant, or prolonged steroid use. Do you have a weakened immune system from a known cause? *

Y

N

I understand the importance of a truthful Health History to assist the doctor in providing the best care possible. I have the opportunity to discuss my Health History with my doctor.

Date * +

First Name *

Last Name *

Doctors Initials (Office Only)

Signature of Person Completing Health History *

clear