COVID-19 Questionnaire – Virginia Beach, VA

Fill Out Our Questionnaire Before Your Appointment

We ask that all of our patients please fill out our COVID-19 screening questionnaire below. If you answer “yes” to any questions, we ask that you plan to reschedule your appointment. If you have any questions or need assistance filling out the form, please let us know.

First Name

Last Name

Date of Birth

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Are you/they having shortness of breath or other difficulties breathing?

Do you/they have a cough?

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you/they experienced recent loss of taste or smell?

Are you/they in contact with any confirmed COVID-19 positive patients?

Is your/their age over 60?

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)