Name

Age

Appointment Date

Temperature

Have you tested positive or are you awaiting test results for COVID-19? Have you tested positive or are you awaiting test results for COVID-19? YesNo

Have you received the COVID-19 Vaccine? Have you received the COVID-19 Vaccine? YesNo

Is there someone who is sick who lives with you at home or who is awaiting COVID-19 Test results or who has tested + for COVID 19? Is there someone who is sick who lives with you at home or who is awaiting COVID-19 Test results or who has tested + for COVID 19?YesNo

Do you have any of the following symptoms now or in the last 48 hours? Do you have any of the following symptoms now or in the last 48 hours? Fever Cough Fatigue Sputum Production Severe Weakness Nasal Congestion or Runny Nose Sore Throat Headache Body or Joint Aches Nausea or Vomiting Diarrhea None of the Above

Have you had any of the following problems in the last 48 hours? Have you had any of the following problems in the last 48 hours? Shortness of Breath Severe Weakness Extreme Tightness in your Chest Fast or Shallow Breathing Difficulty Speaking due to Breathing problems None of the Above

Do you have any of the following conditions? Do you have any of the following conditions? Lung Problems or Respiratory Conditions (Asthma, Emphysema, COPD) Heart Conditions Cancer Diabetes Immuno-compromising illnessess or medications? None of the above