Pre-appointment Questionnaire

Your Name (required)

Your Email (required)

1. Have you previously been diagnosed with COVID-19, or do you think you’ve had/have COVID-19?

YesNo

2. If YES, when and how were you confirmed positive?

N/AI think I had it.I had a positive nasal swab test.I had a positive blood test.I had a positive saliva test.I currently have symptoms and am waiting for a test.

3. If you have had COVID-19, how were you confirmed negative?

N/AI was diagnosed negative by a nasal swab test.I show antibodies to COVID-19 with a blood test.My doctor said I no longer have it because I don’t have any symptoms.I don’t have any symptoms, so I don’t have it.

4. If you have had COVID-19, when were you confirmed negative?

N/A24 hours agoToday10 days after testing

5. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days:

6. Are you in contact with anyone who has been sick and/or confirmed to be COVID-19–positive?

YesNo

7. In the past 14 days have you traveled to any regions affected by COVID-19?

YesNo