Covi
d
-
19 Patien
t Screen
ing Form
Patient's name
First Name
Last Name
Email
example@example.com
Do you/have they have a fever, or have you felt hot or feverish recently? (14-21 days)
Yes
No
If their temperature was taken, was it over 37.8 degrees?
Yes
No
Are you/they having shortness of breath or other breathing difficulties?
Yes
No
Do you/they have a new continuous cough?
Yes
No
Does anyone in your household have a new continuous cough or high temperature?
Yes
No
Any flu like symptoms:-
Gastro-intestinal upset?
Yes
No
Headache?
Yes
No
Fatigue?
Yes
No
Have you/they experienced a recent loss of taste or smell?
Yes
No
Are you/they in contact with any confirmed positive Covid-19 patients?
Yes
No
Is their/your age over 60?
Yes
No
Do you/they have any of the following: -
Heart disease?
Yes
No
Kidney disease?
Yes
No
Lung disease?
Yes
No
Diabetes?
Yes
No
Any auto-immune disorders?
Yes
No
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AM/PM Option
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