COVID-19 Screening Questionnaire | Orthopaedic Associates of Southern Delaware, PA

In order to protect your health and the health of our employees and our community at large, we ask that you answer the following questions regarding Covid 19.

Patient Name *

Date of Birth *

/ /

Provider *

Appointment Date *

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Have you or anyone in your household travelled by air or out of the country in the past 21 days?

Yes

To the best of your knowledge, have you or anyone you have been in close proximity with been exposed to, tested for or confirmed with COVID-19?

Yes

Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell or taste, fever at or greater than 100 degrees Fahrenheit?

Yes

If YES to any of the above please provide a brief explanation?