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COVID-19 Coronavirus Patient Self-Assessment Tool

COVID-19 Coronavirus Patient Self-Assessment Tool

Texas Fertility Center (TFC) is committed to protecting the health and safety of our patients. As our country and our world deal with the novel coronavirus (COVID-19) pandemic, our team is taking measures to protect you. This includes asking you certain questions when you visit our office.

We appreciate you answering the following self-assessment questions each time you visit our office.

  1. Have you had the COVID vaccine  Yes No
  2. If yes, 2nd dose date:___________________
  3. If no, have you had COVID?  Yes ( date: ________ )No 
  4. Are you currently experiencing symptoms of COVID? Yes No
  5. If yes, please explain:________________________________________________