COVID-19 Screening Questions

COVID-19 Screening Questions
Patient Name*

First NameLast Name
Form being filled out by*

First NameLast Name
Date of Upcoming Appointment

MonthDayYear
Date
Phone number reach you for follow-up (if needed)
Please enter a valid phone number.
*We will only call you to follow-up with any positive responses to any of the below questions before proceeding with your appointment. If all questions are negative, we will proceed with your appointment as scheduled.

Out of the health and safety of our other patients, families and our team, we reserve the right to reschedule appointments based on information provided.
Has the patient tested positive or anyone in the household tested positive to COVID-19 and currently in isolation?*

YesNo
If yes, when is isolation scheduled to be complete:
Is anyone in the household currently in quarantine due to COVID-19?*

YesNo
If yes, when is quarantine over:
Does the patient have a fever or have you/they felt hot or feverish recently (14-21 days)?*

YesNo
Any shortness of breath or other difficulties breathing?*

YesNo
Does the patient have a cough?*

YesNo
Any other flu-like symptoms such as gastrointestional upset, headache or fatigue?*

YesNo
Has the patient experienced recent loss of taste or smell?*

YesNo
Has the patient or another family member traveled over the last 2 weeks?*

YesNo
If yes, please list travel destination and activities:
Signature*

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Date*

MonthDayYear
Date
Should be Empty: