Patient Screening Questionnaire

* Patient Name: (Required)

Date:

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

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

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

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.) Yes No

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

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

Are you/they over the age of 60? Yes No

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

If you answered yes, please specify:

Have you/they traveled in the past 14 days? Yes No

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

* Submitted by: (Required)