Screening Questions During COVID-19
Patient Name: _____________________________ Cell # to contact in parking lot: _______________
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PRE-APPOINTMENT |
IN-OFFICE |
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Date: _______
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Date: _______ |
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1. Have you, your child, or a family member been diagnosed If yes, STOP: Patients who are have diagnosed
|
Yes ____ |
No____ |
Yes____ |
No ____ |
2. Are you/they in contact with any confirmed COVID-19
|
Yes ____ |
No ____ |
Yes ____ |
No ____ |
3. Do you/they have fever or have you/they felt hot or
|
Yes ____ |
No ____ |
Yes ____ |
No ____ |
4. Are you/they having shortness of breath or other
|
Yes ____ |
No ____ |
Yes ____ |
No ____ |
5. Do you/they have a cough?
|
|
No ____ |
Yes ____ |
No ____ |
6. Any other flu-like symptoms, such as gastrointestinal
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Yes ____ |
No ____ |
Yes ____ |
No ____ |
7. Have you/they experienced recent loss of taste or smell?
|
Yes ____ |
No ____ |
Yes ____ |
No ____ |
8. Do you/they have heart disease, lung disease, kidney
|
Yes ____ |
No ____ |
Yes ____ |
No ____ |
9. Is your/their age over 60?
|
Yes ____ |
No ____ |
Yes ____ |
No ____ |
10. Have you/they traveled outside of Ohio in If yes, we may consider re-scheduling elective |
Yes ____ |
No ____ |
Yes ____ |
No ____ |