Covid Questionnaire
These questions are in addition to the CDC-recommended questionnaire you will complete at your appointment.
Please answer all the questions on the day of your appointment. Any yes answers will require you to postpone your appointment. Thank you for your consideration of my risk tolerance and for protecting both of us!
In the last 14 days:
Symptoms: Fever (100.4oF/38.0C or greater), chills, repeated shaking/shivering • Cough • Sore throat • Shortness of breath, difficulty breathing • Feeling unusually weak or fatigued* • Loss of taste or smell • Muscle or body aches* • Headache • Runny or congested nose* • Diarrhea • Nausea or vomiting
Please let me know if you or anyone in your household leave the house regularly for work or school. If so, I will require that we work together outside only.
Please answer all the questions on the day of your appointment. Any yes answers will require you to postpone your appointment. Thank you for your consideration of my risk tolerance and for protecting both of us!
In the last 14 days:
- Have you been on an airplane?
- Have you been in close proximity to an individual with any Covid symptoms, whether they have been diagnosed or tested or not?
- Have you attended any indoor gatherings with people not in your household?
- Have you eaten indoors in a restaurant?
- Have you eaten outdoors at the same table with anyone not in your household?
Symptoms: Fever (100.4oF/38.0C or greater), chills, repeated shaking/shivering • Cough • Sore throat • Shortness of breath, difficulty breathing • Feeling unusually weak or fatigued* • Loss of taste or smell • Muscle or body aches* • Headache • Runny or congested nose* • Diarrhea • Nausea or vomiting
Please let me know if you or anyone in your household leave the house regularly for work or school. If so, I will require that we work together outside only.