Patient Screening Form

General Information

Patient Screening

Have you/they recently been tested for COVID-19?

Yes

No

Have you/they tested positive for COVID-19?

Yes

No

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

Yes

No

Are you/they having shortness of breath or other difficulties breathing?

Yes

No

Do you have a cough?

Yes

No

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

Yes

No

Have you/they experienced recent loss of taste or smell?

Yes

No

Are you/they 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

No

Is your/their age over 60?

Yes

No

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

Yes

No

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Yes

No

In the past 2 weeks (14 days) has the patient, caregiver or anyone in your household had contact with any person confirmed to have contracted coronavirus (COVID-19)

Yes

No

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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