COVID-19 Questionnaire

COVID-19 Questionnaire

1. Do you have a fever or have you felt feverish recently (in the past 14 days)?
If yes, STOP and call the office at 480-783-7192 to reschedule your appointment.
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2. Do you have shortness of breath or difficulties breathing?
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3. Do you have a cough?
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4. Do you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
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5. Have you been in contact with any confirmed COVID-19 positive people in the past 14 days?
If yes, please STOP and reschedule your appointment.
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6. Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
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7. Have you traveled in the past 14 days to any regions severely affected by COVID-19 domestically such as New York, or internationally?
If yes, please STOP and reschedule your appointment.
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Patient E-Signature

Date Signed