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 14days? *

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 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 daily for the past 14days? *

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

Loss of smell or taste, or a change in taste

Daily cleaning and
disinfecting of frequently
touched surfaces

Headaches

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

Patient under mandatory isolation

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

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

Date

Signature

Clear