COVID-Questionaire | Mesquite Women's Clinic

MESQUITE WOMEN'S CLINIC
COVID-19 Questionnaire

Serving the Unique Healthcare Needs of Women. Mesquite Women’s Clinic specializes in helping women manage their health through all stages of their lives.

Mesquite Women's Clinic Powered By MedSwift Start Now!

Please provide the following information

First and Last Name

Email Address

Phone

Age

Male Female Non-Binary

Do you have a fever or above normal temperature?

Yes No

Have you experienced shortness of breath or had trouble breathing?

Yes No

Do you have a dry cough?

Yes No

Do you have a runny nose?

Yes No

Have you recently lost or had a reduction in your sense of smell?

Yes No

Do you have a sore throat?

Yes No

Have you been in contact with someone who has tested positive for COVID-19 in the past 14 days?

Yes No

Have you tested positive for COVID-19 in the past 14 days?

Yes No

Have you traveled outside of the US in the past 14 days?

Yes No

COVID Questionnaire

I fully understand and acknowledge the above information, risks, and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By checking this box, I acknowledge that the answers I have provided are true and accurate.

MESQUITE WOMEN'S CLINIC COVID-19 Questionnaire

Please provide the following information

Do you have a fever or above normal temperature?

Have you experienced shortness of breath or had trouble breathing?

Do you have a dry cough?

Do you have a runny nose?

Have you recently lost or had a reduction in your sense of smell?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for COVID-19 in the past 14 days?

Have you tested positive for COVID-19 in the past 14 days?

Have you traveled outside of the US in the past 14 days?

COVID Questionnaire

MESQUITE WOMEN'S CLINIC
COVID-19 Questionnaire