Health Form

Covid19 Questionnaire

You indicated that you experience some symptoms that could be related to Covid19.

Please provide more detailed information, below and we will contact you about scheduling an appointment.

Please check all that apply:

I have traveled outside the country in the last 14 days. During the last 14 days, I have had contact (close or far) with someone who has lab-confirmed COVID-19, is under investigation for COVID-19, or is hospitalized or being treated at home for a respiratory or febrile illness. During the last 14 days, I have had close or distant contact (close=within 6 feet for 5-10 minutes, distant=more than 6 feet for 90+ minutes) with someone who has any symptoms of illness. I have had any of the following symptoms in the past 14 days: Fever or chills, Unexplained cough, shortness of breath or sore throat, Pneumonia/flu symptoms, Loss of smell or change in the sense of taste, Diarrhea, Tiredness, aches. I work in the medical field or other ‘high-risk’ setting.

Covid19 Questionnaire

The Abraham Dayan Mikvah 18181 Burbank Boulevard • Tarzana, California 91356 • 818.758.3836