Covid 19 Corona Virus Assessment

Name (required)

Email (required)

Do you have a fever greater than 100.4?
YesNo

Do you have difficulty breathing or shortness of breath?
YesNo

Have you traveled internationally (in the last 14 days)?
YesNo

Do you have persistent pain or pressure in the chest?
YesNo

Any mental changes such as confusion or inability to arouse?
YesNo

Any blue hues of your lips or face?
YesNo

Have you been around anyone diagnosed with Corona virus?
YesNo

Dr Bragg will review all assessments and email you back. Thank you for participating in FVC/Svelte first Tele-medicine assessment!