COVID-19 Screening COVID-19 PATIENT SCREENING FORMPatient Name:*Patient Date of Birth:* Date Format: MM slash DD slash YYYY Today's Date* Date Format: MM slash DD slash YYYY Do you have a fever or above-normal temperature (>100.4F)?*YesNoAre you experiencing shortness of breath or having trouble breathing?*YesNoDo you have a dry cough?*YesNoDo you have a runny nose?*YesNoHave you recently lost or had a reduction in your sense of smell or taste?*YesNoDo you have a sore throat?*YesNoAre you experiencing chills or repeated shaking with chills?*YesNoDo you have unexplained muscle pain?*YesNoDo you have a headache?*YesNoEven if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?*YesNoHave you been in contact with someone who has tested positive for COVID-19 in the last 14 days?*YesNoHave you been tested for COVID-19 in the last 14 days? If “no” proceed to the next question. If YES, what is the result of the testing?*YesNoHave you traveled out of california in the last 14 days?*YesNoWhat is the result of the Corona Test?*PositiveNegativeI agree to notify the medical practice of Alok Krishna, MD if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the medical practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days. Patient Agreement I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure.Signature of Patient:*
