Patient COVID-19 Screening Form
Fever or felt hot or feverish?
Yes
No
Any shortness of breath or difficulties breathing?
Yes
No
Cough, sore throat, congestion or runny nose?
Yes
No
Any flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Yes
No
Loss of taste or smell?
Yes
No
In contact with any confirmed COVID-19 positive patients?
Yes
No
Patient First Name:
Patient Last Name:
Date of Birth:
Patient / Legal Guardian Signature
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Date:
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