COVID Symptom Checker Contact Information First Name* Last Name* Phone* Email* Screening Information The COVID Symptom Checker must be completed 3 times. Once prior to your appointment, once in the office on the day of your appointment, and once after your appointment. Please indicate which of these you are doing today. Screening Type* —Pre-AppointmentIn-OfficePost-Appointment Patient temp Today’s Date* Screening Questions Do you have a fever, or have you felt feverish recently?* YesNo Do you have a cough?* YesNo Are you having shortness of breath or any difficulty breathing?* YesNo Do you have chills or repeated shaking with chills?* YesNo Do you have any muscle pain?* YesNo Do you have any recent onset of headache or sore throat?* YesNo Do you have any other flu‐like symptoms?* YesNo Do you have any recent loss of taste or smell?* YesNo Have you experienced any recent GI upset such as nausea, vomiting, or diarrhea?* YesNo Are you in contact with anyone who has been confirmed to be COVID‐19 positive?* YesNo Have you traveled outside of the state in the past 14 days?* YesNo Have you traveled by airplane in the past 14 days?* YesNo Have you been tested for COVID‐19?* YesNo What was the result? Have you been diagnosed with COVID‐19? * YesNo What was the date of your diagnosis? Are you over the age of 65?* YesNo Do you have any of the following: Heart disease, Lung disease, Kidney disease, Diabetes, Autoimmune disorders?* YesNo If you get a message that says, “There was an error trying to send your message. Please try again later,” just click “Submit” again. If you continue to get an error message, please contact 970.708.7096 M-F 8 -5 for assistance.