Patient Screening Form

General Information

Patient Name

Today's Date

Patient Screening

Have you/they recently been vaccinated for COVID-19?

Yes

Have you/they recently received a booster shot for COVID-19?

Yes

If yes, when was your/their last shot?

Which vaccination did you/they receive?

Have you/they recently been tested for COVID-19?

Yes

If yes, please specify test date.

Have you/they tested positive for COVID-19?

Yes

If yes, please specify the date of your/their positive test result.

Within the past 14 days, have you/they had a known exposure to any individual suspected or confirmed to have COVID-19 or who has traveled to a location after which self-quarantine is recommended?

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes

Is your/their age over 60?

Yes

Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Yes

Within the past 24 hours, have you/they had any of the following symptoms?

Fever or chills

Yes

Cough

Yes

Shortness of breath or difficulty breathing

Yes

Fatigue

Yes

Muscle or body aches

Yes

Headaches

Yes

New loss of taste or smell

Yes

Sore throat

Yes

Congestion or runny nose

Yes

Nausea or vomiting

Yes

Diarrhea

Yes

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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