Covid - 19 Screening Questionnaire

(Must fill prior to each appointment)

Patient’s Full Name*

Per CDC recommendation, the purpose of this form is to ensure proper infection control procedures are taken for any patients who may have or potentially have been in recent contact with the 2019-nCOV (Coronavirus) to prevent infections from spreading during healthcare delivery. Note that the signs and symptoms of the 2019-nCOV overlap with those associated with other viral respiratory tract infections. Given the time of year, common respiratory illnesses, including influenza, are also considered.

In following both CDC recommendations, this questionnaire is designed with your safety in mind. Your answers will be reviewed prior to your appointment and a member of our team will contact you if we recommend rescheduling to a later date. Thank you for your consideration and understanding.

*NO HANDSHAKING! Use a slight bow, nod, etc.

If yes, approximately how long ago did you test positive? (Hours/Days/Weeks)

If yes, approximately how long ago did you take the test?(Hours/Days/Weeks)

If yes, approximately how long ago did you first notice symptoms? (Hours/Days/Weeks)

4. Are you experiencing any fever, chills, chest pain/tightness, recent onset of severe headaches or loss of smell/taste, or sore throat?

If yes, approximately how long ago did you first notice symptoms? (Hours/Days/Weeks)

5. Have you had close contact with a person infected with COVID - 19 or history of travel in the last 14 days? *

6. Have you had a recent onset of difficulty breathing, unable to eat or drink, or too weak to care for yourself?*

If yes, approximately how long ago did you first notice symptoms? (Hours/Days/Weeks)

7. Are you experiencing any congestion or runny nose, nausea or vomiting, diarrhea, new confusion, inability to wake or stay awake, bluish lips or face, or fatigue?

If yes, approximately how long ago did you first notice symptoms? (Hours/Days/Weeks)

8. Is there anything else our team should know before treating you?

Patient's Signature*

Patient Name*

Date*