PatientPop
WOODLANDS WELLNESS & COSMETIC CENTERCOVID-19 IN-PERSON APPOINTMENT PRE-SCREENING FORMPatient Name:DOB:Appointment Date/Time:Temperature:PRESCREENING QUESTIONNAIRE1. Are you experiencing any of the following:Fever over 100.4New or Persistent coughShortness of breathRunny noseSore throatFatigue, aches and painsSevere GI distress or diarrheaLoss of sense of smell2. Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?YesNo3. Have you been in contact with anyone who has since tested positive for Covid-19?YesNoBy signing below, I confirm that all my answers are honest and correct.Signature: Witness/MA: ................
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