Supplemental Health Questionnaire
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First Name:
MI:
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Last Name:
*
Guardian's Name:
*
Date:
*
1. Does the patient have any of the following: fever, cough, sore throat, shortness of breath and or trouble breathing, fatigue, muscle or body aches, headache, loss of taste or smell, congestion or runny nose?
Yes
No
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2. Has the patient or the guardian accompanying the patient tested positive for COVID in the last 5 days?
Yes
No
3. If you have answered yes to either of the questions, please contact the office 972-315-6100 to see if your appointment needs to be rescheduled.