Modupe Aiyegbusi, MD - Publicforms

Patient Name: *

Date of Birth: *

Have you received the covid-19 Vaccination? If so, please give us Dates and type of Vaccine

Are you currently experiencing, or have experienced in the past 14 days, any of the following symptoms?

Fever or Feeling Feverish? *

Cough *

Shortness of breath or difficulty breathing? *

Sore throat *

New loss of taste or smell *

Chills, Nose Congestion or Runny nose *

Headache, Muscle pain or body aches *

Nausea, Diarrhea, Vomiting or Fatigue *

In the past 14 days, Have you been in close proximity to anyone who was experiencing any of the above symptoms? *

In the past 14 days, Have you been in close proximity to anyone who has tested positive for Covid-19? *

Have you been tested for Covid-19? *

If you tested, what was the result?

List the dates you have been tested for Covid-19

In the past 14 days, Have you been on a commercial flight or traveled outside of the United States? *

In the past 14 days, Have you travelled outside of the Torrance area? *

* Required field