Patient COVID screening form Patient Screening Form Patient Screening Form for covid Use this form before your appointment.Patient Name :(Required) First Last Phone(Required) Please answer the following screening questions. Q1. Are you immunocompromised? * Yes No Q2. Check all symptoms you have. Choose any or all that are new, worsening and not related to other known causes or conditions. ** No symptoms Fever and/or chills Cough or barking cough Shortness of breath Decrease or loss of taste or smell Muscle aches/joint pain Extreme tiredness Sore throat Runny or stuff/congested nose Headache Nausea, vomiting and/or diarrhea Abdominal pain Pink eye Q3. Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or stay at home? Yes No Q4. In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit? Yes No When you arrive at the office, you will be asked to : Sanitize your hands. Have your temperature taken. * Factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals: undergoing cancer chemotherapy with untreated HIV infection with CD4 T lymphocyte count less than 200 with combined primary immunodeficiency disorder on prednisone medication - more than 20 mg per day (or equivalent) for more than 14 days on other immune suppressive medications ** select "NO" if all of these apply : you do not have a fever, AND your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea) CAPTCHA Δ
