COVID-19 Safety Screening Checklist
COVID-19 is a novel coronavirus which has been declared a worldwide pandemic by the World Health Organization. Precautions are being taken to make our office as safe as possible. Thank you for your cooperation and understanding with furnishing this preliminary screening!
Full Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
1. Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
*
Yes
No
2. Are you/they having shortness of breath or other difficulties breathing?
*
Yes
No
3. Do you/they have a cough?
*
Yes
No
4. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
*
Yes
No
5. Have you/they experienced recent loss of taste or smell?
*
Yes
No
Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
*
Yes
No
Is your/their age over 60?
*
Yes
No
Do you/they have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders?
*
Yes
No
Have you/they traveled in the past 14 days?
*
Yes
No
Have you been tested for Covid-19?
*
Yes
No
If yes. When?
*
-
Month
-
Day
Year
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Signature
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