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