Middletown COVID-19 Screening Questionnaire
Before scheduling an appointment, we ask that you complete our quick screening questionnaire.
Please read carefully. Help us and everyone stay safe and healthy!
Symptoms
Have you had any of the following symptoms in the past three days?
Risk Factors
Have you been in close contact (less than six feet) with anyone with COVID-19 or symptoms of COVID-19 in the past 14 days?1
Have you traveled anywhere outside the 50 United States in the past 14 days?
Have you traveled to Rhode Island for a non-work-related purpose from another city, town, county, or state that currently has a stay-at-home restriction, a shelter-in-place restriction, or a similar restriction, declaration, or announcement due to a COVID-19 outbreak?2
Have you been directed to quarantine or isolate by the Rhode Island Department of Health or a healthcare provider in the past 14 days? If so, when does/did your quarantine or isolation period end?
Unfortunately, if you have answered YES to any of the questions above, we are not able to schedule an appointment at this time.
ACKNOWLEDGEMENT
I attest that I have answered NO to all the questions presented.
DISCLOSURES
1. Does not apply to people who come into contact with people with symptoms of COVID-19 during the course of their daily work while wearing full and appropriate personal protective equipment (PPE). See https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html for more information.
2. Public health, public safety, and healthcare workers are exempt. Does not apply to anyone traveling for medical treatment, to attend funeral or memorial services, to obtain necessities like groceries, gas, or medication, to drop off or pick up children from day care, or to anyone who must work on their boats.
