Pre-visit health screening

A quick symptom screen before the appointment, with extra questions only when symptoms exist.

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Pre-visit screening

For everyone's safety, please answer these brief questions within 24 hours of your appointment.

Patient name*

Nombre

Apellido

Contact phone*

Appointment date*

Have you had any symptoms of illness in the past 7 days?*

Yes No

Check the symptoms you've had

Fever or chills Cough Sore throat Shortness of breath Nausea, vomiting, or diarrhea Fatigue or muscle aches Other:

When did the symptoms start?

Tell us a bit more

Have you been in close contact with someone with a confirmed contagious illness in the past 14 days?*

Yes No Not sure

Confirmation*

I confirm my answers are truthful as of today.

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