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COVID-19 Questionnaire
COVID-19 Questionnaire
Full Name
Date of Birth
Patient Temperature Upon Entering Facility:
In the past 14 days,
have you or any household member had any of the following?
Fever?
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Yes
No
Cough?
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Yes
No
Shortness of Breath?
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Yes
No
Chills and Body Aches?
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Yes
No
Sore Throat?
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Yes
No
Diarrhea?
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Yes
No
Nausea/Vomiting?
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Yes
No
Sudden Loss of Taste or Smell?
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Yes
No
Sore Purple or Red Bumps on Your Toes?
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Yes
No
Sore Purple or Red Bumps on Your Fingers?
Please select one.
Yes
No
Hives?
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Yes
No
A suspicion you/housemate may have COVID-19?
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Yes
No
A pending screening test for COVID-19?
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Yes
No
Any exposure to a known or suspected case?
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Yes
No
If you answered “Yes” to any of these, please explain. For example, if you have chronic respiratory or GI symptoms related to a long-standing medical condition, please clarify.
Typing your name here is considered a virtual signature. By signing, you are agreeing that the information provided above is true and valid to the best of your knowledge.
Virtual Agreement
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I agree that the information provided above is true and valid to the best of my knowledge.
I DO NOT agree that the information provided above is true and valid to the best of my knowledge.
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