Back
Appointment Screening Questionnaire
TO BE COMPLETED BY ALL PATIENTS
MASKS MAY BE REQUESTED TO BE WORN IN OUR OFFICE IF RAMSEY COUNTY TRANSMISSION RATE IS HIGH.
Do you have any of the following? Fever, dry cough, shortness of breath, chills, sore throat, flu-like symptoms, or new onset of loss of taste OR smell?
If yes, when?
Have you tested positive for COVID‐19 in the last 2 weeks?
If yes, when?
Have you been in contact with someone who has tested positive for
COVID‐19 in the last 2 weeks?
If yes, when?
IF YOU ANSWERED "YES" TO ANY OF THE ABOVE, PLEASE CALL OUR OFFICE. 651-426-8998.
First
Last
Date Of Birth
Date
Signature
Sign Here
×
Signature Pad
Back
Next
Back
Next
Submit
Done