650howe ave ste730, Sacramento, CA-95825
Monday - Thursday 8.00 AM - 5.00 PM.
Email:
info@mayfairmedsacramento.com
Call: +1 916-999-4535
+1 916-999-4535
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About COVID-19 Screening
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COVID-19 Screening
COVID-19 PATIENT SCREENING FORM
Patient Name
Patient Date of Birth
Today's Date'
Do you have a fever or above-normal temperature (>100.4F)? *
Yes
No
Are you experiencing shortness of breath or having trouble breathing? *
Yes
No
Do you have a dry cough? *
Yes
No
Do you have a runny nose? *
Yes
No
Have you recently lost or had a reduction in your sense of smell or taste? *
Yes
No
Do you have a sore throat?*
Yes
No
Are you experiencing chills or repeated shaking with chills? *
Yes
No
Do you have unexplained muscle pain? *
Yes
No
Do you have a headache? *
Yes
No
Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days? *
Yes
No
Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days? *
Yes
No
Have you been tested for COVID-19 in the last 14 days? If "no" proceed to the next question. If YES, what is the result of the testing? *
Yes
No
Have you traveled out of california in the last 14 days? *
Yes
No
I agree to notify the medical practice of Alok Krishna, MD if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the medical practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.
Patient Agreement
I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure.
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