COVID-19 Pre-visit Patient Screening Form All patients and their vistor must complete a pre-visit online form for exposure risk to COVID-19 and symptoms of respiratory illness prior to their appointment.PATIENT NAME First Last Visitor Name (if applicable) First Last Date MM slash DD slash YYYY Have you, your visitor with you today or a family member had direct contact with an individual with confirmed coronavirus (COVID-19) in the LAST 14 DAYS? Yes No Have you, your visitor with you today or a family member had direct contact with a person who is currently being quarantined for corona virus (COVID-19) exposure in the LAST 14 DAYS? Yes No Have you or your visitor with you today had any of the following symptoms in the past 3 days?Fever Yes No Cough Yes No Shortness of breath Yes No Loss of smell or taste Yes No Chills Yes No Repeated shaking chills Yes No Muscle pain Yes No Headache Yes No Sore throat Yes No *If the answer is NO to all of the above, the patient may come in on their scheduled appointment date. *If the answer is YES to any of the above, the patient will be advised to call their primary care doctor and reschedule their appointment. Covid-19 Testing Questions:Have you been tested for COVID-19 in the past 72 hours? Yes No Date of test MM slash DD slash YYYY *Was the test positive? Yes No *Was the test negative? Yes No If the test was positive, patient needs to reschedule at least 14 days after symptoms are gone or are cleared by their primary care doctor.COMMENTS
