Covid-19 pre appointment check

*

1. Question 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?*

Required - Required.

Yes

No

Comments:

This is required

*

2. Question 2.

WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED NEW SHORTNESS OF BREATH THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION?*

Required - Required.

Yes

No

Comments:

This is required

*

3. Question 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?

Required - Required.

Yes

No

Comments:

This is required

*

4. Question 4.

WITHIN THE LAST 14 DAYS, HAVE YOU HAD A TEMPERATURE AT OR ABOVE 37.8°C OR THE SENSE OF HAVING A FEVER?*

Required - Required.

Yes

No

5. Question 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)*

Yes

No

Comments:

This is required

*

6. Question 6.

WITHIN THE LAST 14 DAYS, HAVE YOU OR A HOUSEHOLD MEMBER BEEN ISOLATING?*

Required - Required.

Yes

No

Comments:

This is required

*

7. Question 7.

Patient's Name and phone number

Required - Required.

8. Question 8.

If you answer yes to any of these questions, please reschedule your appointment

I understand