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Date

Questionnaire

1. Have you been sick in the last 14 days? YesNo

2. Have you had a fever including low grade temperature in the last 14 days? YesNo

3. Do you have a cough, trouble breathing, runny nose, or sore throat? YesNo

4. Do you have any other signs or symptoms of being sick? YesNo

5. Have you been around anyone who is sick in the last 14 days? YesNo

6. Have you had an exposure to a known COVID-19 patient? YesNo

7. Have you had an exposure to someone with the flu? YesNo

8. Have you traveled to any of the affected areas - China, Italy, Iran, South Korea, Japan, Washington state, California, New York, DC, YesNo

9. Have you taken a cruise in the past 14 days? YesNo

Be Advised

Form Section

If you have answered yes to any of these questions YOU MAY NOT come into our office for 14 days or until your symptoms clear. Also please note that our doctor and staff are refraining from hand shaking and direct hand to hand contact. Premier Pain Specialists, LLC is committed to keeping everyone safe and healthy during this challenging time. We are reminding our employees about frequent hand washing, and we are regularly cleaning and disinfecting our facilities and equipment. Importantly, we are asking that our employees stay home from work if they feel sick.

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