Health-Screening Questionnaire

The safety of our patients and staff is of utmost importance to Hope Springs. Given the recent COVID-19 outbreak, we ask you answer the following question before your appointment. These are designed to help promote your safety, as well as the safety of our staff and other patients. We are asking the same questions to all practice patients to help ensure everyone’s safety. So that we can ensure that you receive care at the appropriate time and setting, please answer these questions truthfully and accurately. All of your responses will remain confidential. As appropriate, the information you provide will be reviewed you may be provided additional guidance regarding whether any adjustments need to be made to your scheduled appointment.

Have you or a member of your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever, temperature at or greater than 100 degrees Fahrenheit?

Have you or a member of your household tested positive for COVID-19?

Were you or a member of your household advised to self-quarantine for COVID-19 by government officials or healthcare providers?

Have you or a member of your household been advised to be tested for COVID-19 by government officials or healthcare providers?

Have you or a member of your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?

Have you or a member of your household traveled outside the U.S. in the past 30 days?

Have you or a member of your household traveled elsewhere in the U.S. in the past 21 days?

Have you or a member of your household traveled on a cruise ship in the last 21 days?

Are you or a member of your household healthcare providers or emergency responders?

Have you or a member of your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?

Do you have any reason to believe you or a member of your household has been exposed to or acquired COVID-19?

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?

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