Note: Each question is to be answered for the patient coming for the flu vaccine. If you are bringing multiple children, you may print one form and answer for all children, specifying any differences in answers by writing on the form.


Patient name(s): ________________________________

1. Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva, in the past 14 days?



2. In the last 48 hours, have you had any of the following NEW symptoms? 











3. In the past 14 days, has a medical professional advised you to get tested for COVID-19?



                                                Parent Name: __________________ Date: _______
 
                                                Parent Signature: ___________________________

Form adapted from The Mayo Clinic
Call us at (301) 625-2800
Please call us with any questions
Screening Questions for COVID Risk Assessment
Complete prior to drive-up flu clinic appointment
Bring completed form with you on day of appointment
YesNo
Fever greater than or equal to 100.4 degrees Farenheit
Trouble breathing, shortness of breath, or wheezing
Cough
Loss of smell or taste, or change in taste
None of the above
YesNo