Source: Project AesCert
TM
Guidance, May 2020
Pre-Screening
In-Office Screening
Date:
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Month
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Day
Year
Date
SYMPTOM WELLNESS CHECK:
1. Have you experienced any of the following symptoms within the last 14 days? Fever or feeling feverish? New cough? Shortness of breath? Flu-like symptoms such as fatigue, nausea, diarrhea? Chills? Repeated shaking with chills? Muscle pain? Headache? Sore throat? New loss of taste and smell? Rash? Please be specific or answer no:
2. Are any family members or any immediate/close contacts currently sick or experiencing any of the following symptoms within the last 14 days? Fever or feeling feverish? New cough? Shortness of breath? Flu-like symptoms such as fatigue, nausea, diarrhea? Chills? Repeated shaking with chills? Muscle pain? Headache? Sore throat? New loss of taste and smell? Rash? Please be specific or answer no:
3. Have any family members or close friends been diagnosed or suspected of having Coronavirus or COVID 19?
4. Have you been diagnosed or suspected of having Coronavirus or COVID 19?
If yes, when?
Have you been tested for Coronavirus or COVID-19? If tested, was testing performed by nasal swab or blood test? Specify if positive or negative!
Have you had an antibody test for Coronavirus? Specify if positive or negative!
If known, was the test for IgM or IgG antibodies?
RECENT TRAVEL:
Have you or any family members recently traveled in the U.S. or internationally?
If Yes, when?
NOTES:
Patient Name:
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