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Supplemental Health Questionnaire

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Supplemental Health Questionnaire

This form is used to screen patients the day of their appointment due to the COVID virus.

Page 1

Please answer the following questions to help us ensure your safety and the safety of others.

Email*

What is your full name?*

What is your date of birth?*

Select date

Have you traveled outside of...*

Have you been in close conta...*

Yes

Description:Screen patients for COVID with our Supplemental Health Questionnaire. This form is designed to be used on the day of the appointment to ensure the safety of everyone involved.

Our Supplemental Health Questionnaire is an essential tool to screen patients for COVID-19. Designed to be used on the day of the appointment, this form ensures the safety of everyone involved. By asking relevant questions about symptoms, exposure, and travel history, our questionnaire helps identify potential COVID cases and take necessary precautions to prevent the spread of the virus. With our easy-to-use form, you can streamline your screening process and provide a safe environment for your patients and staff.

Full Name*

Phone Number*

Address*

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Full Name*

Phone Number*

Address*

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First Name*

Last Name*

Date of Birth*

Select date

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What is your first name?*

What is your last name?*

What is your date of birth?*

Select date

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Full Name*

Address*

Phone Number*

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Introduction*

Consent*

I have read and understand the information provided.

I have had the opportunity to ask questions and have had them answered to my satisfaction.

I consent to participate in telehealth services.

Patient Name*

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What is your age?*

What is your gender?*

How long have you had tinnitus?*

Less than 3 months

3-6 months

6-12 months

More than 1 year

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Full Name*

Date of Birth*

Phone Number*

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What is your age?*

What was the date of your appointment?*

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