Coronavirus -COVID-19 Self Declaration Screening Form

For the health and safety of our patients, office staff and community, declaration of illness is required. Be sure that the information you'll give is accurate and complete.

Unfortunately due to COVID Pandemic we are no longer provide any “In-office consults”, all consults must be exclusively via phone consults, photos, videos and/or virtual, unless prearranged, thorough screening process, evidence of negatively COVID PCR Tests results within 24hrs and management approval.

We are no longerallowed to have anyone enter the office unless they have a scheduled appt. Pre-approval must be requested if needed due special needs circumstances at time appt is made, proof of negative COVID PCR test results within 24hrs and will be submitted for management approval.

Thank you for your understanding, cooperation and assistance in ensuring your safety as well as our staff, provider, families and community

Please seek immediate medical attention if you have any of the COVID-19 signs.

Name *

First Name Last Name

Date of Birth

Date

Phone Number *

Area Code Phone Number

Email

example@example.com

Today's Date *

Date

Have you had new onset of any of the following symptoms within the last 48hrs? *

	Yes	No	Not sure
Fever 100.5 degrees F or above
Cough
Shortness of Breath or Trouble breathing, or severe wheezing
Sore Throat
Headaches
Muscle aches or Body aches
Loss of Taste or Smell, or change in Taste or Smell
Diarrhea

Have you had any of the following symptoms within the last 30days? *

	Yes	No	Not sure
Fever 100.5 degrees F or above
Cough
Shortness of Breath or Trouble breathing, or severe wheezing
Sore Throat
Headaches
Muscle aches or Body aches
Loss of Taste or Smell, or change in Taste or Smell
Diarrhea

Have you had any of the following symptoms within the last 30days? *

	Yes	No	Not sure
Fever 100.5 degrees F or above
Cough
Shortness of Breath or Trouble breathing, or severe wheezing
Sore Throat
Headaches
Muscle aches or Body aches
Loss of Taste or Smell, or change in Taste or Smell
Diarrhea

Have you been within 6 feet or taken care of anyone within the past 14 days diagnosed with COVID-19? *

Yes No

Have you been within 6 feet or taken care of anyone within the past 14 days with any symptoms of Fever, Cough, Shortness of Breath, Chills or Sweats, Anosmia, Upper Respiratory Infections, Cold like symptoms, Sore Throat? *

Yes No

Have you had any recent Air, Train or Cruise Ship travel within the last 30days? *

Yes No

Have you traveled Internationally recently within the last 30days? *

Yes No

Have you had the COVID Vaccine?

No Yes, Moderma 1st Dose Yes, Moderma 1st & 2nd Dose Yes, Pfzier 1st Dose Yes, Pfizer 2nd Dose Yes, Johnson & Johnson

If YES, Date of COVID Vacccination Date

Have you traveled domestically recently within the last 30days? *

Yes No

Have you gathered at a social gathering within the last 3wks with more than 5 people that normally you do not live in your same household? *

Yes No

Have you been wearing a face-covering outdoors or in outings? *

Yes No

How many weeks have you been self-quarantined? *

Greater than 3weeks Less than 3weeks

Are you taking any steps to prevent the spread of COVID-19? *

	Yes	No
Social Distancing
Reducing or avoiding travel
Frequently washing hands
Staying home if sick
Avoiding close contact with others and crowds if NOT vaccinated
Daily cleaning and disinfecting of frequently touched surfaces

Do you have any of the following pre-existing condition(s): *

	Yes	No
Asthma
Lung Disease
Diabetes
Cancer
Heart Disease
Auto-Immune DIsease

I understand if I have any of the following criteria on day of visit, I will NOT qualify to be seen and will need to be rescheduled

	Informed
Patient has a fever 100.5 degrees Fahrenheit or above
Patient is currently symptomatic, EVEN despite vaccination, because you can still transmit COVID to others
Patient has had confirmed Covid-19 within 30 days of scheduled appointment
Patient with acute respiratory symptoms such as cough, difficulty breathing, or showing symptoms as stated above within the last 3 weeks.
Patient with complaints of a recent loss of taste or smell
Patient with significant medical comorbidities, and highly immunosuppressed
Been COVID Vacinated less than 4weeks or Pending COVID 2nd Vaccination

I acknowledge that the information I've given is accurate and complete.

Date

Signature

Clear