COVID-19 (English)
Have you experienced recent loss of taste or smell?
YES
NO
CORONAVIRUS (COVID-19) SCREENING QUESTIONNAIRE
YES
Date: 5/9/2025
Do you have a cough, or have you had a cough within the last 48 hours?
Have you been diagnosed with coronavirus (COVID-19)?
YES
Do you have fever or had fever recently (14-21 days)?
YES
Signature will be recorded later.
Signature will be recorded later.
YES
NO
Have you had flu like symptoms or gastrointestinal upset within the last 48 hours?
Have you had close contact with an individual diagnosed with COVID-19?
YES
PATIENT SIGNATURE:
NO
NO
NO
NO
REVIEWED BY (STAFF MEMBER):
PLEASE arrive alone with a face covering.
NO
Do you have heart disease, lung disease or kidney disease or diabetes?
YES
Birthdate:
Last Name:
First Name:
Are you having shortness of breath or other difficulties breathing?
NO
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
YES
Is your age over 60?
NO
YES
Have you travelled to a country designated as Level 2 or 3 by the CDC?
NO
YES