COMMUNICATION
SCIENCES
& ORAL HEALTH
TEXAS
WOMAN'S
UNIVERSITY
Name: _________________________________________ Date: ____________ Time: ___________
Phone: _____________________________ Email: ________________________________________
□ Patient □ Family/Friend of Patient Name: ____________________________________
1. Have you or anyone in your household experienced symptoms of fever, cough, shortness of breath or
other flu-like symptoms in the last 14 days? YES NO
2. Have you had direct contact with anyone who is known to have tested positive for COVID-19
coronavirus in the last 14 days? YES NO
If YES, where and when: __________________________________________________
3. Have you or anyone in your household traveled abroad in the last 14 days to any countries with a Level
3 Travel Health Notice including, but not limited to: China, Iran, South Korea, Europe? States with
reported COVID-19 cases? YES NO
If YES, where and when: __________________________________________________
4. Do you work at any of the facilities listed below that have or has had any positive cases of COVID-19
coronavirus in the last 30 days?
● Healthcare(hospital, outpatient, rehabilitation)
● Senior living facility,
● Prison or detention center,
● State supported living center
YES NO
If YES, where and when: __________________________________________________
5. Does anyone in your household work, volunteer or attend school at a facility that is known to have or
has had any positive cases of COVID-19 in the last 30 days? YES NO
If YES, where and when: __________________________________________________
