Lazzara- AAOIC Supplemental Health Questionnaire

AAOIC Supplemental Health Questionnaire

Prior to each appointment, all patients are required to answer the questions that follow before coming to their appointment.
Patient Name *
Who is filling out this form? *

Patient Guardian
Is the patient a minor? *

Yes No
1. Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *

Yes No
If yes, when?
Date
2. Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:
A Fever (defined as above 99.6 degrees) *

Yes No
A Cough? *

Yes No
Shortness of Breath and/or Trouble Breathing? *

Yes No
Persistent Pain, Pressure, or Tightness in the Chest? *

Yes No
3. Has the individual contacted with people that were infected, suspected or diagnosed with COVID-19? *

Yes No
Parent/Guardian Name
Signature

Clear
Sender
Email
example@example.com
Should be Empty: