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?

YesNo
2 - Has the patient, caregiver, or anyone in the household travelled outside of Illinois in the past 2 weeks?

YesNo
3 - Has the patient, caregiver, or anyone in the household had contact with anyone suspected to have contracted covid-19?

YesNo
4 - Has the patient, caregiver, or anyone in the household had contact with any person confirmed to have contracted covid-19?

YesNo
5 - Has the patient or caregiver currently been exposed to anyone with flu-like symptoms? (Cough, shortness of breath or fever)

YesNo
6 - Are you, caregiver, or anyone in the household currently experiencing any of the following symptoms? Please check if "yes"

FeverCoughSore throatShortness of breath, wheezing, difficulty breathingMuscle achesStomach painsVomiting or diarrheaPink/red eyesFatigue 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