COVID-19 Screening 
Please return this form within 24 hours of your appointment time. Please keep in mind , if you answer "yes" to the first 4 questions, Oregon Health Authority REQUIRES rescheduling of appointment until symptoms have been resolved, and fever has been resolved without medication for at least 72 hours, or at least 14 days after contact with a person sick with cough, fever, or diagnosed COVID-19. I will also have to reschedule if I have encountered the same. Thank you.
Have you had a cough?
Have you had a fever?
Have you had shortness of breath?
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?
Can you exercise to get your heart rate and respiratory rate up without any problem?
Have you had a new onset of muscle aches and pain since the emergence of the virus?
Have you seen any new marks, rashes, spots, bumps or other lesions on your skin?

Thanks for submitting!

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