COVID-19 Wellness Questionnaire

Please review the following questionnaire prior to your next appointment. If you can answer YES to any of these questions, please give our office a call as we may have to reschedule.

• Do you have a cough?

• Are you experiencing shortness of breath or difficulty breathing?

• Do you have a fever now or have you in the past 10 days?

• Have you experienced recent loss of taste or smell?

• Are you experiencing other flu-like symptoms such as gastrointestinal upset, headache, or fatigue?

• Have you had a positive COVID-19 test in the past 14 days?

• Have you come in contact with any confirmed COVID-19 positive patients in the past 10 days?

• Have you done any indoor socializing in the last 14 days without you or others being masked?

Thank you for your cooperation and understanding as we continue to maintain the health and safety of our patients and staff.