COVID-19 Screening Questionnaire

Aesthetic Plastic Surgery 905 Fifth Ave., New York, NY10021 Phone:(929)505-2060

1. Do you have:

A temperature of 100.4 degrees Fahrenheit or higher:*

A cough:*

Shortness of breath or difficulty breathing:*

2. Do you have heart disease, lung disease, kidney disease or diabetes*

3. Have you traveled in the past 14 days to regions affected by COVID-19? If so, where?*

4. Have you been in close contact with anyone who a has a confirmed COVID-19 diagnosis?*

5. Have you traveled within the US or internationally within the past 2 months, or had close contact with anyone who has traveled in the past 2 months? *

6. Have you had contact or came in close proximity with anyone with confirmed labproven COVID19 in the last 14 days?*

7. Has anyone in your family or close work associates had confirmed, possible or suspected COVID-19 in the last 14 days?*

8. Do you work in a higher-risk occupation, such as health care worker, first responder, frontline service worker, or grocery store/airline/airport/cruise-ship worker?*

9.Have you experienced the following symptoms (Appear 2-14 days after exposure to the COVID19 virus):

i. Fever (100.0°F)
ii. Dyspnea, cough, or other respiratory symptoms
iii. Shortness of breath
iv. Muscle aches/pain
v. GI symptoms (nausea, vomiting, diarrhea)
vi. Loss of appetite
vii. Loss of taste or smell
viii. Conjunctivitis
ix. Chills / repeated shaking with chills
x. Extreme fatigue
xi. Blue discoloration/ blisters of toes
xii. Age > 65 confused, dizzy, falls, mental status changes

If you answered yes to any of these questions, please call your primary care provider or your State Department of Health for further direction.

Patient Signature

Date