Steelsmith Natural Health Center

COVID-19 Patient Screening Questionnaire

All questions marked with an asterisk (*) are required and must be completed before you are able to submit the survey.

Patient Name * Date of Birth *

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 * Head or muscle aches * Nausea, diarrhea, vomiting * 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 yes, what was the result? List the date of test In the past 14 days, have you been on a commercial flight or traveled outside the United States *