Patient Screening Form

Patient Screening Form


1 Do you have fever or have you/they felt hot or feverish recently (14-21 days)?   Yes  or  No

 2.Are you/they having shortness of breath or other difficulties breathing?  Yes  or  No

 3. Do you/they have a cough? Yes or No

 4. Any other flu-like symptoms, such as gastrointestinal upset, headaches or fatigue? Yes  or  No

 5. Have you/they experienced recent loss of taste or smell? Yes  or  No

 6.Are you/they in contact with any confirmed COVID-19 positive patients?  Yes  or  No

 Patients who are well but how have a sick family member at home with COVID-19 should

   consider postponing elective treatment.

 7. Is your/their age over 60? Yes or No

 8. Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?  Yes  or  No

 9. Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) Yes  or  No


Contact Us. We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form below.