COVID-19 Pre-Appointment Questions Patient Name* First Last Today Date* Date Format: MM slash DD slash YYYY Appointment Date* Date Format: MM slash DD slash YYYY Do you/(s)he have fever or have felt hot or feverish within the past 14 days?*YesNoDo you/(s)he have shortness of breath or any breathing difficulties?*YesNoDo you/(s)he have a cough?*YesNoAny flu-like symptoms (ie muscle aches, gastrointestinal upset, headache, or fatigue)?*YesNoRecent loss of smell or taste?*YesNoBeen in contact with any person(s) confirmed to be COVID-19 positive?*YesNo(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?*YesNoSignaturePositive responses may warrant a deeper discussion with the doctor and possible rescheduling of the appointment for the safety of our team members and patients.
