Screening Questions During COVID-19

Patient Name: _____________________________                       Cell # to contact in parking lot:  _______________

 

 

PRE-APPOINTMENT

IN-OFFICE

 

 

 

Date:  _______

 

 Date:  _______

 

1.    Have you, your child, or a family member been diagnosed
      with COVID-19? 

      If yes, STOP: Patients who are have diagnosed
     with and currently have COVID-19 will not be seen until
     cleared with med form.

 

 

 Yes  ____

 

  No____

 

   Yes____

 

  No ____

 

2.    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 will need to  postpone elective
       treatment.

 

 

 Yes  ____

 

 No  ____

 

 Yes  ____

 

 No  ____

 

3.    Do you/they have fever or have you/they felt hot or
       feverish recently (14 days)?

 

 Yes  ____

 No  ____

 Yes  ____

 No  ____

 

4.    Are you/they having shortness of breath or other
       breathing difficulties?

 

 

  Yes  ____

 

 No  ____

 

 Yes  ____

 

 No  ____

 

5.    Do you/they have a cough?

 

 
Yes  ____

 

No  ____

 

 Yes  ____

 

 No  ____

 

6.    Any other flu-like symptoms, such as gastrointestinal
       upset, headache, or fatigue?

 

 

  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
       disease, diabetes or any auto-immune disorders?

 

 

 

  Yes  ____

 

 

 No  ____

 

 

  Yes  ____

 

 

  No  ____

 

9.    Is your/their age over 60?

 

 Yes  ____

 No  ____

 Yes  ____

 No  ____

10.   Have you/they traveled outside of Ohio in
        the past 14 days? If yes, when, where, for how long? 

      If yes, we may consider re-scheduling elective
      care dependent on answer.

 Yes  ____

 No  ____

 Yes  ____

 No  ____