COVID-19 Patient Screening Form Pre-Treatment COVID-19 Screening Questions Patient Name* First Last Email* Phone*Do you have a fever or above normal temperature?*YesNoHave you experienced shortness of breath or had trouble breathing?*YesNoDo you have a dry cough?*YesNoDo you have a runny nose?*YesNoHave you recently lost or had a reduction in your sense of smell?*YesNoDo you have a sore throat?*YesNoHave you been in contact with anyone who has tested positive for COVID-19?*YesNoHave you been tested for COVID-19 but still awaiting results?*YesNoHave you traveled outside the U.S. in the last 14 days?*YesNoI fully understand and acknowledge the above information, and have disclosed to my provider any conditions in my health history.Patient or Guardian Signature*PhoneThis field is for validation purposes and should be left unchanged.