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
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Yes ____ |
No____ |
Yes____ |
No ____ |
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2. Are you/they in contact with any confirmed COVID-19
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Yes ____ |
No ____ |
Yes ____ |
No ____ |
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3. Do you/they have fever or have you/they felt hot or
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Yes ____ |
No ____ |
Yes ____ |
No ____ |
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4. Are you/they having shortness of breath or other
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Yes ____ |
No ____ |
Yes ____ |
No ____ |
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5. Do you/they have a cough?
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No ____ |
Yes ____ |
No ____ |
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6. Any other flu-like symptoms, such as gastrointestinal
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Yes ____ |
No ____ |
Yes ____ |
No ____ |
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7. Have you/they experienced recent loss of taste or smell?
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Yes ____ |
No ____ |
Yes ____ |
No ____ |
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8. Do you/they have heart disease, lung disease, kidney
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Yes ____ |
No ____ |
Yes ____ |
No ____ |
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9. Is your/their age over 60?
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Yes ____ |
No ____ |
Yes ____ |
No ____ |
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10. Have you/they traveled outside of Ohio in If yes, we may consider re-scheduling elective |
Yes ____ |
No ____ |
Yes ____ |
No ____ |