Covid19 Patient Screening Form

* Patient Name: (Required)

Date:

Do you have a fever or have you felt feverish recently (the last 14-21 days)? Yes No

Are you having shortness of breath or other difficulties breathing? Yes No

Do you have a cough or have had a cough recently? Yes No

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

Have you experienced recent loss of taste or smell? Yes No

Are you in contact with any confirmed COVID-19 positive patients or have you been exposed to COVID-19? Yes No

Are you currently waiting on the results of a pre-travel or post-travel COVID-19 test? Yes No

Are you over the age of 60? Yes No

Do you have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders? Yes No

If you answered yes, please specify:

Have you traveled in the past 14 days? Yes No

If you answered yes, please specify where you traveled and when you returned:

Have you been fully vaccinated against COVID-19? Yes No

* Submitted by: (Required)