PATIENT SCREENING FORM PATIENT'S NAME * First Name Last Name Do you have a fever or have you felt hot recently (14 - 21 days)? * Please complete the following form. Skip past the "IN OFFICE" questions as those will be completed at your appointment. YES NO IN OFFICE: Are you having shortness of breath or other difficulties breathing? YES NO Do you have a cough? YES NO Any flu-like symptoms,gastrointestinal upset, headache or fatigue? YES NO Have you experienced recent lose of smell or taste? YES NO Are you or have you been in contact with any confirmed COVID-19 positive patients? YES NO Have you traveled in the past 14 days to any regions affected by COVID-19? YES NO ACKNOWLEDGEMENT * * By checking this box, I acknowledge that I have read and answered the questions to the best of my knowledge. Please sign if this form is not completed online. Date, completed by patient MM DD YYYY Date, reviewed "IN OFFICE" MM DD YYYY OFFICE USE: Thank you!
