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Pre-appointment Questionnaire

1. Have you previously been diagnosed with COVID-19, or do you think you’ve had/have COVID-19?

2. If YES, when and how were you confirmed positive?

3. If you have had COVID-19, how were you confirmed negative?

4. If you have had COVID-19, when were you confirmed negative?

5. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days:

Altered or loss of taste/smell:
Dry cough:
Trouble breathing
Shortness of breath, difficulty breathing, chest tightness
Blueish lips or face
Chills/repeated shaking with chills
Muscle pain
Headache or sore throat
Any other flu-like symptoms
GI upset or diarrhea

6. Are you in contact with anyone who has been sick and/or confirmed to be COVID-19–positive?

7. In the past 14 days have you traveled to any regions affected by COVID-19?

Some medical conditions have been associated with more severe COVID-19 disease. The following questions are an attempt to determine your risk

8. Are you over age 65?

9. Do you have high blood pressure?

10. Do you have diabetes?

11. Are you overweight?

12. Do you have respiratory problems?

13. Do you have any autoimmune disorders?

14. Are there any other conditions you would like to report?