COVID-19 Patient Screening Questionnaire

COVID-19 Patient Screening Questionnaire
A. Do you have a fever, or have you felt feverish recently?

YesNo
B. Do you have chills or repeated shaking with chills?

YesNo
C. Have you experienced shortness of breath or had trouble breathing?

YesNo
D. Do you have a dry cough?

YesNo
E. Have you recently lost or had a reduction in your sense of smell or taste?

YesNo
F. Do you have a sore throat?

YesNo
G. Do you have muscle pain?

YesNo
H. Do you have a recent onset of headache or sore throat?

YesNo
I. Do you have any other flu-like symptoms?

YesNo
J. Have you experienced any recent GI upset or diarrhea?

YesNo
K. Have you been in contact with someone who has tested positive for COVID-19?

YesNo
L. Have you tested positive for COVID-19?

YesNo
M. Have you been tested for COVID-19 and are awaiting results?

YesNo
N. Have you traveled outside the USA by air or cruise ship in the past 14 days?

YesNo
If you are over the age of 65, do you have the following diseases?

Heart diseaseLung diseaseKidney diseaseDiabetesAutoimmune disorders
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Patient's Name
Signature

Clear
Signature Date

MonthDayYear
Date
Should be Empty: