Fill out the Covid-19 QuestionnaireCovid Questionnaire Full Name * Date of Service * Do you have fever above 100.4 F * Yes NoAre you experiencing any of the following symptomsA cough * Yes NoShortness of breath * Yes NoLoss of taste of smell * Yes NoAny flu like symptoms such as upset stomach, headache, fatigue or pains * Yes NoHave you been in contact with someone who has tested positive for Covid-19 in the last 14 days * Yes No If yes, what was the date. Cannot be seen till 14 days after that date. Have you been tested for Covid-19 in last 14 days * Yes NoWhat is the result of the testing * +Ve : You must come back 14 days after free of symptoms. -Ve Waiting : You must come back after results are backHave you travelled anywhere during the last 14 days? * Yes NoYou have to be in quarantine for 14 days before you can come before coming for appointmentAre you over 60? * Yes NoDo you have any heart disease, lung disease, kidney disease, diabetes or any other auto immune disease? * Yes No Please List If you are human, leave this field blank. Submit