Surveypoint

Q1

Patient's Name

First Name

Q2

Patient's Name

Last Name

Q3

Email

Q4

Phone Number

Q5

Age

Q6

Address

Street Address

Q7

Address

Street Address Line 2

Q8

Address

City

Q9

Address

State / Province

Q10

Address

Postal / Zip Code

Q11

Please select the doctor that you would like to see.

Doctor Name 1

Doctor Name 2

Doctor Name 3

Doctor Name 4

Q12

1. In the past 14 days, have you or the the patient traveled or lived in area with a probable/ confirmed case of COVID-19?

Yes

No

Q13

2. In the past 14 days, have you or the the patient contacted closely with probable/ confirmed case of COVID-19?

Yes

No

Q14

3. Which of the following symptoms have you or the patient experience in the past 14 days?

Fever

Cough

Sore Throat

Shortness of Breath

Difficulty of Breathing

Diarrhea

Eye Itch

Please Specify

Q15

4. Which of the following conditions apply to you or the patient?

60 years old or above

with pre-existing medical conditions (Asthma, Liver Disease, Diabetes, Chronic Lung Disease, etc.)

Diagnosed as high-risk pregnancy

Health worker

Q16

Pre Appointment -Form Fill

Patient's Name

Patient's Name

Email

Phone Number

Age

Address

Address

Address

Address

Address

Please select the doctor that you would like to see.

1. In the past 14 days, have you or the the patient traveled or lived in area with a probable/ confirmed case of COVID-19?

2. In the past 14 days, have you or the the patient contacted closely with probable/ confirmed case of COVID-19?

3. Which of the following symptoms have you or the patient experience in the past 14 days?

4. Which of the following conditions apply to you or the patient?

Patient's Signature