COVID-19 CHECK-IN

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COVID-19 CHECK-IN

COVID-19 CHECK-IN

Please check the following questions and submit to complete your daily check-in.

Name

First

Last

Cellphone # *

Do I have a fever (higher than 100.3 degrees) or new respiratory symptoms such as cough, shortness of breath or sore throat? *

Yes
No

Have I traveled to a Covid-19 affected area outside of the U.S. in the past 14 days? *

Yes
No

Have I had close contact (been within six feet for over 15 minutes or lived with) a person with Covid-19 in the past 14 days? *

Yes
No

Have I been diagnosed with Covid-19 or told be a health care provider that I might have or have Covid-19? *

Yes
No

***IF YOU ANSWERED “YES” TO ANY OF THE PRIOR (4) QUESTIONS, PLEASE NOTIFY YOUR CONTACT AT OUR OFFICE.***

Spoke with Patient/CG PRIOR to visit for Covid Questionnaire, denies coming into contact with anyone who has tested positive or S/S of Covid, traveled outside of the country or denies coming into contact with someone suspicious of possibly being exposed to Covid. *

Yes
No

PATIENT stated has no fever, no coughing, sore throat, difficulty breathing or any COVID symptoms and allowed for VISIT. *

Yes
No

I will use MASK and appropriate PPE. *

Yes
No

Please add any comments to your submission here.

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COVID-19 CHECK-IN