COVID-19 PATIENT SCREENING QUESTIONNAIRE

COVID-19 SCREENING QUESTIONNAIRE In response to the continued Coronavirus (COVID-19) Pandemic, Dr. Kelly Gaiotti is taking precautions to protect everyone at this facility including patients, staff, and visitors. Therefore, we are asking all patients and visitors to complete this screening form prior to each appointment (24 hours before your visit) or upon arrival. Thank you for your cooperation.

- The Dorset PHYSIO Team

Please review the following self screening criteria: *

	Yes	No
Has the patient or anyone in the family (household) tested positive for COVID-19 in the past 14 days?
Has the patient or anyone in the family (household) been tested for COVID-19 and are awaiting results?
Does the patient or anyone in the family (household) have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath, or Loss of Taste and Smell?
Does the patient or anyone in the family (household) have any GI symptoms? Diarrhea? Nausea?
Even if you don’t currently have any of the above symptoms, has the patient or anyone in the family (household) experienced any of these symptoms in the last 14 days?
Has the patient or anyone in the family (household) been in contact with someone who has tested positive for COVID-19 in the last 14 days?
Has the patient or anyone in the family (household) traveled outside the United States by air or cruise ship in the past 14 days?

If answered YES to any of the above questions, your appointment will be rescheduled and you are required to take a COVID-19 test and show proof of a negative result prior to your next appointment (either a PCR or Antigen Test is allowed). If you do not meet the criteria above, please sign below indicating that you have been provided with this information. I HAVE REVIEWED THE ABOVE CRITERIA AND I DO NOT HAVE SYMPTOMS AS DESCRIBED.
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