Novel Coronavirus Screening Questionnaire

Name*

First Last

DOB*

MM

DD

YYYY

Have you or anyone at your residence traveled outside the U.S.A in the last 14 days? (Hidden)*

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

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

Do you have any of the additional symptoms:

Fever or feeling feverish?*

Shortness of breath?*

New headache*

Chills?*

A new sore throat?*

New loss of taste or smell?*

New Muscle Aches*

Loss of Taste (Hidden)*

Name of Person*

First Last

Phone Number*

Dates and Location of Travel*

Signature of person completing this questionnaire*

Relationship to patient/minor (if applicable)

Date

MM

DD

YYYY