Novel Coronavirus Screening Questionnaire

Name*

First Last

DOB*

MM

DD

YYYY

Have you and/or anyone accompanying you today traveled outside of the United States in the last 2 weeks?*

Yes
No

Where and when?*

Have YOU tested positive for COVID-19?*

Yes
No

When did you test positive for COVID-19?*

Have you and/or anyone accompanying you today been in close contact with a person known to have 2019 Novel Coronavirus?*

Yes
No

When?*

Do you and/or anyone accompanying you today currently have a fever/feeling feverish or any respiratory symptoms such as shortness of breath?*

Yes
No

Do you have any of the additional symptoms:

Fever more than 100.4*

Yes
No

New Muscle Aches*

Yes
No

New Loss of Taste*

Yes
No

New Loss of Smell*

Yes
No

New Cough*

Yes
No

A New Sore Throat?*

Yes
No

New Headache*

Yes
No

Chills*

Yes
No

Shortness of breath? (Hidden)*

Yes
No

New loss of taste or smell? (Hidden)*

Yes
No

Because you answered yes to one of the above:

Name of Person*

First Last

Phone Number*

Dates and Location of Travel*

Signature

Signature of person completing this questionnaire*

Relationship to patient/minor (if applicable)

Date

MM

DD

YYYY