COVID-19 Pre-Screening Questionnaire
Due to the ongoing Covid-19 Pandemic, all patients are required to complete this form prior to being seen at Alzein Pediatrics Urgent Care.
Please answer the following questions below:
Yes
No
Has the patient, caregiver, or
anyone in the household
travelled outside the US in the past 2 weeks?
Has the patient, caregiver, or anyone in the household
travelled outside of Illinois in the past 2 weeks?
Has the patient, caregiver, or anyone in the household had
c
ontact with anyone
suspected to have contracted covid
-19?
Has the patient, caregiver, or anyone in the household had
contact with any person confirmed to have contracted
covid
-
19?
Has the patient or caregiver currently been exposed to
anyone with flu like symptoms?
(Cough, shortness of breath
or fever)
Are you, caregiver or anyone in the household currently experiencing any of the following symptoms?
Yes
No
Fever
Cough
Sore Throat
Shortness of breath, wheezing or difficulty breathing
Muscle Aches
Stomach Pains
Vomiting or Diarrhea
Pink/Red Eyes
Rash
Fatigue or Feeling Unwell
By signing below, you certify that the answers above are true and that there is no information being withheld.
Patient Name:
DOB:
Patient/Caregiver Signature:
Clear
Date:
/
Month
/
Day
Year
Date
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Submit
Should be Empty: