Patient Name*

Email*

Mobile Number*

Color and model of car*

Have you tested positive for COVID-19 or awaiting the results?*

Do you have a fever?*

Do you have any shortness of breath?*

Do you have a dry cough?*

Do you have a runny nose?*

Do you have a sore throat?*

Do you have sneezing, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies?*

Have you experienced headaches, fatigue, or weakness?*

Have you lost your sense of taste and/or smell?*

Within the last 14 days, have you travelled to any foreign country?*

Within the last 14 days, have you travelled within the united states?*

If so, where?

Although exposure is unlikely, do you accept the risk and give consent to treatment?*

Name

Date

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Covid-19 Form Questionnaire