COVID-19 SCREENING TOOL

COVID SCREENING

Patient's name: *

Are you fully Vaccinated? *

Yes

Partially

Booster?

Have you ever been tested for COVID-19? *

YES

If so, what were your results? *

POSITIVE

NEGATIVE

NEVER TESTED

If you have tested positive within the last 30 days, due to office policy we do require for a negative COVID test to be provided at the time of your appointment

If positive, what date did you test positive for COVID-19? +

Have you had a negative result after the date you tested positive?

YES

If negative, what date did you test negative for COVID-19? +

Have you traveled outside of the United States within the last 2 weeks? *

YES

Do you now have or have you, in the past 2 weeks, had a cough, sore throat, headache, chills, muscle pain, or a fever of 100 degrees or higher? *

YES

Have you been within 6 feet of someone who has been exposed, potentially been exposed or currently has COVID-19? *

YES

IF yes, what was the exposure date? +

Do you commit to notifying Bay Area Orthopaedic & Sports Specialist within 24 HOURS, if you find out you have been exposed, or potentially exposed to COVID-19 prior to your visit? *

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