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?*

PatientGuardian
Is the patient a minor?*

YesNo
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?*

YesNo
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)*

YesNo
A Cough?*

YesNo
Shortness of Breath and/or Trouble Breathing?*

YesNo
Persistent Pain, Pressure, or Tightness in the Chest?*

YesNo
3. Has the individual contacted with people that were infected, suspected or diagnosed with COVID-19?*

YesNo
Parent/Guardian Name
Signature

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