COVID – 19 Pre Screen Questionnaire

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COVID-19 Questionnaire

If you can answer yes to any of these questions, then we ask that you call ahead for specific instructions for your appointment or medication refill. You may be asked to fill out a questionnaire and  have your temperature taken when you arrive.

    Your Name:
    Your Email:

    Do you have or have you had a fever above 100 degrees in the past 14 days?

    Have you recently lost or had reduction in your sense of smell?

    Do you or have you had any other Flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

    Do you have a dry cough?

    Do you have shortness of breath or other difficulties in breathing?

    Have you been in contact with someone who has tested positive for COVID-19 (corona virus) within the past 14 days?

    Have you traveled outside of the US or been around anyone who has been outside the US in the past 14 days?

    Have you tested positive for COVID-19 in the past 14 days, or are you awaiting test results for COVID-19?


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