COVID19 Questionnaire


Patient & Contact Information

Symptoms within the last 14 Days

Exposure History

Unprotected close contact - being within approximately six (6) feet or two (2) meters from a person with COVID-19 for approximately five (5) minutes or longer and not wearing a face mask.

COVID-19 History

Vaccination against COVID-19

Informed Consent (Please write down your initials after each statement.)