MVP Family Practice & Sports Medicine, Inc.

7800 Florence Ave. Downey, CA 90240 Tel: 562-928-5700 Fax: 562-928-5707

www.mvpmedicine.com | info@mvpmedicine.com

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Patient Information
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* All information above is confidential and subject to all applicable laws under HIPPA. No information provided will be shared without prior written consent.
 COVID-19 Screening Questionnaire 
1. Do you currently have or recently been diagnosed with a confirmed case of COVID-19 (Coronavirus)?
2. Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva, in the past 14 days?
3. Does the person with COVID-19 live with you?
4. Are you ill, or caring for someone who is ill?
5. Have you had a fever of 100.5 F (38 C) or above, or possible alternating chills and sweating?
6. Do you have a Cough?
7. Do you have or recently did have trouble breathing, shortness of breath or severe wheezing?
8. Do you have or recently did have chills or repeated shaking with chills?
9. Do you have or recently did have muscle aches?
10. Do you have or recently did have a Sore throat?
11. Do you have or recently did have loss of smell or taste, or a change in taste?
12. Do you have or recently did have Nausea, vomiting or diarrhea?
13. Do you have or recently did have Headache?
14. Do you have or recently did have bluish lips or face?
15. Do you have Employees or Co-Workers who have symptoms of acute respiratory illness?
16. Do you have Employees or Co-Workers who are well with a sick family member with COVID-19?
17. Do you live in or visit a place where COVID-19 is spreading?

© 2020 by MVP Family Practice & Sports Medicine, Inc.

For Life-Threatening Emergencies Call 911

Tel: 562-928-5700

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