SHF 2020 Coronavirus Screening

  1. Are you currently experiencing these symptoms (flu like symptoms)? Please check all that apply:⬜ Fever
    ⬜ Cough
    ⬜ SoreThroat
    ⬜ Shortness of Breath
  2. Have you been exposed to anyone that has been self-isolating for Coronavirus (COVID-19)?⬜ YES Where______________________Date________________________⬜ NO
  3. Have you been to any areas where the virus has been diagnosed in the population?⬜ YES⬜ NO

*China, Iran, Italy, Japan and South Korea, U.S. states with recent cases.

{NOTATION: If you answer “yes” to any of the above, please contact the clinic to speak to the nurse before you come for your appointment. Your health is important to us and our provider team can help triage your immediate medical needs via a telehealth visit.)