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COVID-19 Questionnaire
Patient's Name:
*
Parent/Guardian Name:
Patient/Guardian Email:
*
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, within the past 14 days, traveled outside the country?
*
Yes
No
Have you come into contact with a person with confirmed 2019-nCoV infection within the past 14 days?
*
Yes
No
Have you traveled through or to/from one of the states included on the NYS Restricted States list?
Yes
No
Do you have any updates to the patient's Health History? (new medications, surgeries, insurance changes, etc.)
*
Yes
No
Patient/Parent's Signature
*
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