Coronavirus Screening Questions 1. Have you felt like you have had a fever, flu-like symptoms, persistent shortness of breath, or an abnormal dry cough in the past two months? Yes No 2. Have you traveled outside of the US within the last 4-6 weeks? Yes No 3. Have you been in close contact with an individual, including a health care worker, who has confirmed COVID-19? Yes No 4. Have you gathered in large groups of more than 10 individuals without social distancing in the past two weeks? Yes No 5. Have you ever tested positive for COVID-19? Yes No We are currently requesting that If you marked YES to any of the above questions you please contact the office right away to discuss and/or possibly reschedule your exam for a later date. We are dedicated to providing a safe environment for our patients and staff and appreciate your understanding and participation. Please sign and return this form at your appointment. I attest that to the best of my knowledge the following answers are true and correct.Patient/Guardian signatureDate MM slash DD slash YYYY