Covid19 Patient Screening Form

Covid-19 Wellness Screening Form - 2020
Do you have a fever or have you felt feverish recently (the last 14-21 days)?
Are you having shortness of breath or other difficulties breathing?
Do you have a cough or have had a cough recently?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you experienced recent loss of taste or smell?
Are you in contact with any confirmed COVID-19 positive patients or have you been exposed to COVID-19?
Are you currently waiting on the results of a pre-travel or post-travel COVID-19 test?
Are you over the age of 60?
Do you have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders?

Have you traveled in the past 14 days?

Have you been fully vaccinated against COVID-19?
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