COVID-19 PATIENT SCREENING QUESTIONNAIRE
*Indicate Yes or No and provide relevant comments.
Patient Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Screening Questions
Rows
Pre-Appointment*
In-Office*
Post-Appointment* follows up with the patient 2 days post-appointment to ask if they have developed symptoms or have been diagnosed with COVID-19.
Do you have a fever, or have you felt feverish recently?
Yes
No
Yes
No
Do you have a cough?
Yes
No
Yes
No
Are you having shortness of breath or any difficulty breathing?
Yes
No
Yes
No
Do you have chills or repeated shaking with chills?
Yes
No
Yes
No
Do you have any muscle pain or body aches?
Yes
No
Yes
No
Do you have any recent onset of headache or sore throat?
Yes
No
Yes
No
Have you been experiencing nausea and/or vomiting?
Yes
No
Yes
No
Do you have any recent loss of taste or smell?
Yes
No
Yes
No
Have you been experiencing fatigue recently?
Yes
No
Yes
No
Have you experienced any recent GI upset or diarrhea?
Yes
No
Yes
No
Have you been advised to self-quarantine because of exposure to someone with COVID-19?
Yes
No
Yes
No
Have you traveled in the past 14 days to any regions affected by COVID-19?
Yes
No
Yes
No
Have you been tested for COVID-19?
Yes
No
If yes, what was the result?
Have you been diagnosed with COVID-19?
Yes
No
If yes, when?
Are you over the age of 65?
Yes
No
Do you have:
Heart disease
Lung disease
Kidney disease
Diabetes
Autoimmune disorders
Submit
Should be Empty: