COVID-19 Pre-Screening Questionnaire

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

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

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
Should be Empty:

Please answer the following questions below: