Patient Covid-19 Form Patient Covid-19 Form Location —Please choose an option—Marysville, WAAuburn, WA Do you have a fever or have you felt hot/feverish recently? (14-21 days)? YesNo Are you having shortness of breath or other difficulties breathing? YesNo Do you have a cough? YesNo Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? YesNo Have you experienced a recent loss of taste or smell? YesNo Have you been in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. YesNo Are you over the age of 60? YesNo Do you have any heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? YesNo Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) YesNo
