CORONAVIRUS (COVID-19) SCREENING QUESTIONNAIREYESDate: 12/4/2020Do you have a cough, or have you had a cough within the last 48 hours?Have you been diagnosed with coronavirus (COVID-19)?YESDo you have fever or had fever recently (14-21 days)?YES
Signature will be recorded later.
Signature will be recorded later.
YESNOHave 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?YESPATIENT SIGNATURE:NONONONOREVIEWED BY (STAFF MEMBER):PLEASE arrive alone with a face covering.NODo you have heart disease, lung disease or kidney disease or diabetes?YESBirthdate:Lastname:firstname:Are you having shortness of breath or other difficulties breathing?NOPatients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.YESIs your age over 60?NOYESHave you travelled to a country designated as Level 2 or 3 by the CDC?NOYESNOYESHave you experienced recent loss of taste or smell?