Patient Name*

First Last

Today Date*

Appointment Date*

Do you/(s)he have fever or have felt hot or feverish within the past 14 days?*

Yes
No

Do you/(s)he have shortness of breath or any breathing difficulties?*

Yes
No

Do you/(s)he have a cough?*

Yes
No

Any flu-like symptoms (ie muscle aches, gastrointestinal upset, headache, or fatigue)?*

Yes
No

Recent loss of smell or taste?*

Yes
No

Been in contact with any person(s) confirmed to be COVID-19 positive?*

Yes
No

(Patients who are well but have a sick family member at home with COVID-19 should reschedule the appointment to 14 days later.)

Traveled by bus, plane, or train outside of South Carolina in the past 14 days?*

Yes
No

Signature

Positive responses may warrant a deeper discussion with the doctor and possible rescheduling of the appointment for the safety of our team members and patients.