COVID-19 Screening Please fill out the form below 1 day prior to your appointment: Your Name: Appointment Date: Are you immunocompromised*? YesNo *Factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of immunocompromised include individuals undergoing cancer chemotherapy, with untreated HIV infection with CD4 lymphocyte count less than 200, with combined primary immunodeficiency disorder, on prednisone medication (more than 20 mg per day or equivalent for more than 14 days), on other immune suppressive medications. Do you have any of the following symptoms*? YesNo *Select No if all of these apply: you do not have a fever and your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting and/or diarrhea) Fever and/or chills Cough or barking cough Shortness of breath Decrease or loss of taste or smell Muscle aches/joint pain Extreme tiredness Sore throat Runny or stuffy/congested nose Headache Nausea, vomiting and/or diarrhea Abdominal pain Pink eye Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating, or staying at home?YesNo In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?YesNo Signature: Press the button below to submit the completed screening form.