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Patient Screening Questionnaire

Covid-19 Wellness Screening Form -
Do you/they have a fever or have you/they felt feverish recently (the last 14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough or have had a cough recently?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
(Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.)
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients or have you/they been exposed to COVID-19?
Are you/they over the age of 60?
Do you/they have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders?

Have you/they traveled in the past 14 days?

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