In Order to reduce the risk of spreading COVID-19 , we have asked you a number of “ screening” questions below. For the safety of our staff ,other patients, and yourself, please be truthful and candid in your answers.
Patient Name
Date:
Has the patient or anyone in the same household have been tested positive with Covid-19 in the last 30 days?
YES
NO
Are you or anyone In the house hold currently awaiting the results of a COVID-19 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 difficulties breathing? Any 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 the US in the past 14 days?
YES
NO
**** Answering “Yes” to any of these questions would likely indicate a deeper discussion with Front Desk Staff before being seen, and possibly rescheduling of your appointment will be required for the safety of our office staff and patients. We appreciate your patience and understanding during these unprecedented times.
Signature
Date