Health survey pre-appointment

Last name *

*

First name *

*

Age *

*

Phone number

E-mail

Do you suffer from heart, lung, kidney or liver problems? *

Yes

No

If yes, specify

Do you have unbalanced diabetes? *

yes

No

Do you have a condition or treatment that lowers your immunity? *

Yes

No

If yes, specify

Your height

Your weight

Are you pregnant in the 3rd trimester of pregnancy? *

yes

No

To date and in the past 3 weeks have you had any of the following symptoms *

*

A person with the above signs? *

Yes

No

A person diagnosed with COVID-19? *

Yes

No

ave you tested positive for COVID-19? *

Yes

No

Number of days since the end of having a cold *

*

Number of days since the end of a respiratory difficulty *

*

Number of days since onset of symptoms *

*