COVID-19 Pre-Appointment Questions Patient Name* First Last Today Date* MM slash DD slash YYYY Appointment Date* MM slash DD slash YYYY 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 SignaturePositive responses may warrant a deeper discussion with the doctor and possible rescheduling of the appointment for the safety of our team members and patients.