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COVID-19 Questionnaire
Patient's Name:
*
Parent/Guardian Name:
Patient/Guardian Email:
*
If you are experiencing any COVID-19 symptoms please contact us to reschedule your appointment.
Do you have a fever or have you experienced a fever within the past 14 days?
*
Yes
No
Have you experienced a recent onset of respiratory problems, such as a cough or difficulty in breathing within the past 14 days?
*
Yes
No
Have you in the last 14 days traveled outside a 150 mile radius of Santa Clara County?
*
Yes
No
Have you come into contact with a person with confirmed COVID-19 infection within the past 14 days?
*
Yes
No
Have you come into contact with people from confirmed cities, surrounding areas or people from a neighborhood with recent documented fever or respiratory problems within 14 days?
*
Yes
No
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