COVID-19 Screening COVID-19 Screening Patient's Name(Required) First Last Patient's Date of Birth(Required) Month Day Year Office Location(Required) Cranberry/Seven Fields Pleasant Hills Squirrel Hill/Greenfield Does the patient have a fever (temperature > 100.4 F)?(Required) Yes No Does the patient have a new or worsening cough?(Required) Yes No Does the patient have difficulty breathing or shortness of breath?(Required) Yes No Does the patient have a loss of taste or smell, or a sore throat?(Required) Yes No Has the patient been, for at least 15 minutes, in close contact (< 6 feet) with someone with a laboratory confirmed case of COVID-19?(Required) Yes No Has the patient or anyone in your household been tested for COVID-19 in the past 14 days?(Required) Yes No Please indicate who and when, and whether they were positive.(Required)CAPTCHA
