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Coronavirus Screening Questionare

Do you currently or in the last five days have had a fever or temperature over 100.4F? *

Do you currently or in the last five days have you experienced shortness of breath or had trouble breathing? *

Do you currently or in the last five days have you had a dry cough? *

Do you currently or in the last five days have you had a sore throat? *

In the last five days have you been in contact with someone who has tested positive for COVID‐19? *

In the last five days have you tested positive for COVID‐19? *

In the last five days have you been tested for COVID‐19 and are awaiting results? *

Have you traveled outside the United States by air or cruise ship in the past 14 days? *

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.