COVID-19 SCREENING QUESTIONNAIRE
To reduce the spread of COVID-19, please respond to the screening questions below. For the safety of yourself, our staff, and other patients, please be truthful in your answers.
General Information
TODAY’S DATE:
NAME:
Has the patient or anyone in the same household been tested positive for COVID-19 in the last 30 days?
YES
NO
Are you or anyone in the same household currently awaiting the results of a COVID19 test result?
YES
NO
Has the patient been exposed to anyone confirmed positive with COVID-19 and has been quarantined in the last 30 days?
YES
NO
Is the patient having shortness of breath or difficulties breathing?
YES
NO
Does the patient have a cough?
YES
NO
Has the patient experienced any flu-like symptoms, such as fever, headache, fatigue, nasal congestion, upset stomach, or sore throat?
YES
NO
Has the patient experienced any recent loss of taste or smell?
YES
NO
Has the patient traveled anywhere in the US or outside in the US in the last 14 days?
YES
NO
*** ANSWERING “YES” TO ANY OF THESE QUESTIONS WILL LIKELY INDICATE A NEED FOR A DEEPER DISCUSSION WITH OUR FRONT DESK STAFF BEFORE BEING SEEN BY MEDICAL PERSONNEL AND POSSIBLY A RESCHEDULING OF YOUR APPOINTMENT. THIS IS TO ENSURE THE SAFETY OF OUR OFFICE STAFF AND OTHER PATIENTS. WE APPRECIATE YOUR PATIENCE AND UNDERSTANDING DURING THESE UNPRECEDENTED TIMES. ***
Signature of Patient/Legal Guardian
Date