Section 1 of 1 in this document
COVID-19 Risk Assessment Form
Patient Name
*
Date
*
Have you had a fever, cough, shortness of breath, sore throat, any new loss of smell or taste, muscle pain, or flu-like symptoms in the past 14 days?
Yes
No
Have you been near or had physical contact with anyone who has had these symptoms or has been diagnosed with COVID-19 in the past 14 days?
Yes
No
Have you traveled outside of Texas in the last 14 days?
Yes
No
If yes, where have you traveled?
Have you been in contact with anyone who has traveled to Texas from somewhere else?
Yes
No
If yes, from where?
disregard this