Patient Screening Form

Patient Name

Email Address

Phone

Are you filing this form out in-office or before your appointment? Are you filing this form out in-office or before your appointment? In-Office Pre-Appointment

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? 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? Are you/they having shortness of breath or other difficulties breathing? Yes No

Do you/they have a cough or a sore throat? Do you/they have a cough or a sore throat? Yes No

Any other flu-like symptoms, such as gastrointestinal upset, nausea, diarrhea, headache or fatigue? Any other flu-like symptoms, such as gastrointestinal upset, nausea, diarrhea, headache or fatigue? Yes No

Have you/they experienced recent loss of taste or smell? 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 treatment. 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 treatment. Yes No

Is your/their age over 60? Is your/their age over 60? Yes No

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? 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 COVID-19? (as relevant to your location) Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) Yes No