COVID Questionnaire COVID Questionnaire Patient First Name * Patient Last Name * Patient Age * Child's temperature taken today * Does your child currently or have they had a fever or felt feverishly within the last 14-21 days? * Yes No Does your child have a cough? * Yes No Has your child had any shortness of breath or any other difficulties breathing? * Yes No Has your child had any other flu-like symptoms, such as upset stomach, headache or tiredness? * Yes No Has your child had any recent loss of taste or smell? * Yes No Have you or your child been in contact with anyone who has tested positive for COVID-19? * Yes No Does your child have heart disease, lung disease, kidney disease, diabetes, or auto-immune? * Yes No Who accompanied child and entered building to pay? * Accompanying adult's temperature * Submit