Patient Screening Form

General Information

Patient Name

Today's Date

Patient Screening

Have you recently been tested for COVID-19?

Yes

If yes, please specify test date.

Have you tested positive for COVID-19?

Yes

Do you have fever or have you felt hot or feverish recently (14-21 days)?

Yes

Are you having shortness of breath or other difficulties breathing?

Yes

Do you have a cough?

Yes

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes

Have you experienced recent loss of taste or smell?

Yes

Are you in contact with any confirmed COVID-19 positive patients?

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes

Is your age over 60?

Yes

Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Yes

Have you traveled in the past 14 days to any regions affected by COVID-19?

(as relevant to your location)

Yes

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit