Patient Name:
Date:
Has the patient or anyone in the same household tested positive with Covid-19 in the last 30 days?
*** Patients who are well but have a sick family member at home with Covid-19 will be asked to reschedule appointment
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? Any Cough?
Yes
No
Has the patient experienced any flu like symptoms, such as fever, headache, fatigue, nasal congestion, or upset stomach?
Yes
No
Has the patient experienced any recent loss of taste or smell?
Yes
No
Does the patient have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Yes
No
Is there someone in the household over the age of 60?
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.