EmailMe Form - COVID-19 Screening Survey [OLD]

Name of Patient being Treated *

First Last

1. Are you fully vaccinated against COVID-19 and/or aged 11 or younger?

Yes

No

2. Have you tested positive for COVID-19 in the past 5 days (if fully vaccinated) or 10 days (if unvaccinated) or have you been told you should be isolating? *

Yes

No

3. In the last 5 days (if fully vaccinated) / 10 days (if unvaccinated), have you experienced any of these symptoms?

• Fever and/or chills
• Continuous cough or barking cough
• Shortness of breath
• Decrease or loss of taste or smell
• Unusual muscle aches/joint pain
• Extreme tiredness
• Painful sore throat
• Runny or stuffy/congested nose - not related to allergies
• Nausea, vomiting and/or diarrhea - not related to any existing conditions *

Yes

No

4. Do you live with someone who is currently isolating because of a positive COVID-19 test, has COVID-19 symptoms or is
waiting for COVID-19 test results?

Select “No” if you:
• if you fully vaccinated, or
• completed your isolation after testing positive in the last 90 days *

Yes

No

I, verify that the answers I provided on this form to be truthful and honest. It is my responsibility to notify the office if any of the answer changes before my appointment. *

Yes

No

Updated Changes in Our Office:

1. You are no longer required to wear a mask when you enter the office.

2. When you arrive, you no longer have to call our office and wait in the car. You are welcome to come inside and check-in.

3. You will be asked to use hand sanitizer when you enter and exit the office.

4. We will ask some screening questions again, related to COVID-19 when you enter the office.