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COVID-19 Screening Questionnaire
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COVID-19 Screening Questionnaire
Covid Screening
Name
*
Date
*
Time
Practitioner
*
Part A: In the past 24 hours, have you experienced:
Sore Throat
New or worsening cough
Shortness of breath or difficulty breathing
Sudden loss of smell
Body Temperature (LEAVE BLANK - TEMPERATURE WILL TAKEN AT THE CLINIC )
Submit
If you are human, leave this field blank.
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