About COVID-19
COVID-19 PreScreen Form
Please Submit Requested Information
Name:
*
1. Are you experiencing any of the following COVID symptoms?
Yes
No
a. felt feverish or had a fever of 100.4 or greater in the past 24 hours
b. cough not related to another medical condition
c. trouble breathing
d. short of breath
e. hurts to take a deep breath
f. muscle aches not related to a medical condition or any recent physical activity
g. chills
h. loss of taste or smell not related to another medical condition
i. vomiting or diarrhea in the past 24 hours not related to another medical condition
2. Has anyone in your household tested positive for COVID-19?
*
Yes
No
2.a. Have you called the IOC?
*
Yes
No
3. Do you have a COVID-19 test pending?
*
Yes
No
3.a. Did you get tested due to having symptoms?
*
Yes
No
Thank you for all you are doing for our patients and families.