COVID-19 Patient Screening Form

COVID-19 Patient Screening Form
IMPORTANT NOTICE:
If you have ANY of the following symptoms:

CALL 911 OR SEEK EMERGENCY MEDICAL CARE AT THE NEAREST HOSPITAL
- Difficulty breathing
- Persistent pain or pressure in the chest
- New onset confusion
- Inability to wake or stay awake
- Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Any other flu-like symptoms, such as a gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients? (Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.)
Is your/their age of 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Positive responses to any of these questions may indicate the need for COVID-19 testing.
Should be Empty:

IMPORTANT NOTICE: