|
Patient Name:
Phone Number:
Email Address:
|
Pre-Appointment |
In-Office |
| Date:
|
Date: |
| Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? |
|
Yes No |
| Are you/they having shortness of breath or other difficulties breathing? |
|
Yes No |
| Do you/they have a cough? |
|
Yes No |
| Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? |
|
Yes No |
| Have you/they experienced recent loss of taste or smell? |
|
Yes No |
Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective tretment. |
|
Yes No |
| Is your/their age over 60? |
|
Yes No |
| Do you/they have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders? |
|
Yes No |
| Have you/they traveled in the past 14 days to any regions affected by COVID19? (as relevant to your location) |
|
Yes No |
