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

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, your visitor with you today or a family member, been to a state in the last 14 days for which NJ requires a 14 day quarantine?

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

*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

COVID-19 Pre-visit Patient Screening Form

Dr. Walter Shurminsky O.D.