Periago COVID-19 Health Screening Questionnaire

Have you recently participated in any large gatherings of people you didn’t know?

Have you or a member of your household traveled outside the United States within the last 14 days?

Have you or an immediate family member been sick or had a fever in the last 14 days?

Have you come into close contact with someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days?

Do you have a fever greater than 99.6 degrees fahrenheit OR symptoms of possible COVID-19 Infection?

If you answered YES to the last question, please select any and all symptoms you are experiencing:

Start date of symptoms: 


If you are experiencing symptoms, have you been tested for COVID-19?

What was the COVID-19 Test Result?

What was the date of the COVID-19 Test Result?


Patient or Parent/Guardian Signature


Date Signed