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1. COVID-19 pre-screening questionnaire
(please complete no more than 24 hours before your appointment)
WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED A NEW COUGH THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION?* *
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2. WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED NEW SHORTNESS OF BREATH THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION?* *
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3. WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED A NEW SORE THROAT, LOSS OF TASTE OR SMELL THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION? *
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4. WITHIN THE LAST 14 DAYS, HAVE YOU HAD A TEMPERATURE AT OR ABOVE 37.8°C OR THE SENSE OF HAVING A FEVER?* *
5. WITHIN THE LAST 14 DAYS, HAVE YOU HAD CLOSE CONTACT WITH SOMEONE WHO IS OR WAS SICK WITH SUSPECTED OR CONFIRMED COVID-19? (NOTE: CLOSE CONTACT IS DEFINED AS WITHIN 6 FEET FOR MORE THAN 10 CONSECUTIVE MINUTES)*
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6. WITHIN THE LAST 14 DAYS, HAVE YOU OR A HOUSEHOLD MEMBER BEEN ISOLATING?* *
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7. Patient's Name and phone number *
8. If you answer yes to any of these questions, please reschedule your appointment