Urgent Care Pre-Screening

Urgent Care Patient Pre-Screening

Due to the ongoing Covid-19 Pandemic, all patients are required to complete this form prior to being seen at Alzein Pediatrics Urgent Care.
1 - Has the patient, caregiver, or anyone in the household travelled outside the US in the past 2 weeks?

Yes No
2 - Has the patient, caregiver, or anyone in the household travelled outside of Illinois in the past 2 weeks?

Yes No
3 - Has the patient, caregiver, or anyone in the household had contact with anyone suspected to have contracted covid-19?

Yes No
4 - Has the patient, caregiver, or anyone in the household had contact with any person confirmed to have contracted covid-19?

Yes No
5 - Has the patient or caregiver currently been exposed to anyone with flu-like symptoms? (Cough, shortness of breath or fever)

Yes No
6 - Are you, caregiver, or anyone in the household currently experiencing any of the following symptoms? Please check if "yes"

Fever Cough Sore throat Shortness of breath, wheezing, difficulty breathing Muscle aches Stomach pains Vomiting or diarrhea Pink/red eyes Fatigue or feeling unwell
By signing below, you certify that the answers above are true and that there is no information being withheld.
Patient Name *

First Name Last Name
Date of Birth
MM/DD/YYYY
Patient/Caregiver Signature

Clear
Date of Signature
MM/DD/YYYY
Should be Empty:

Urgent Care Patient Pre-Screening