COVID-19 Pre Screening Questionnaire

COVID 19 Pre-Screening Questionnaire

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you have a fever or have you felt hot or feverish in the past 14-21 Days? *
Are you having shortness of breath or difficulties breathing? *
Do you have a cough *
Are you experiencing any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *
Have you experienced recent loss of taste or smell? *
Have you been or are you in contact with any confirmed COVID-19 Positive patients? *
Is your age over 60? *
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *
Have you traveled in the past 14 days to any regions affected by COVID-19? *
UPON ARRIVAL PLEASE CALL 216.521.0737 TO LET THE FRONT DESK KNOW YOU ARE HERE

Patients must wear a face covering or mask. Upon entering the office we will take your temperature and re ask you these same set of questions. Please leave purses, jackets, and personal items in your car. Adult patients must come in alone, no extra family members/friends allowed in the room. If the appointment is for a child, an adult can accompany them.
Signature *

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Should be Empty:

COVID 19 Pre-Screening Questionnaire