COVID-19 SCREENING QUESTIONNAIRE

COVID-19 SCREENING QUESTIONNAIRE

In response to the recent Coronavirus (COVID-19) outbreak, Daleen Boshoff is taking precautions to lessen the spread of the virus. All patients must have a screening form completed prior to visiting my practice.

Name / Naam*

First Name / VoornameSurname / Van

Cell / Sel*

Format: (000) 000-0000.

Please review and complete the following self screening criteria: *

Rows	Yes	No
1. Have you been in contact with anyone diagnosed with COVID-19??
2. Do you have the following symptoms?
Cough
Fever
Sore throat
Running Nose
Difficulty with breathing / shortness of breath
3. 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?
5. Did you provide any health care or received any health care during the last 14 days?
6. Do you agree to adhere to social distancing of 1,5m?
7. Do you agree to wearing a mask?
8. Do you agree to sanitise your hands or wash your hands with soap and water before and after the session?

Date*

Date

Signature*