Covid 19 Patient Screening Form

Covid 19 Patient Screening Form
Address *
Address
City
State/Province
Zip/Postal
These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions:
Do you have a fever or above normal temperature? *
Have you experienced shortness of breath or had trouble breathing? *
Do you have a dry cough? *
Do you have a runny nose? *
Have you recently lost or had a reduction in your sense of smell? *
Do you have a sore throat? *
Have you been in contact with someone who has tested positive for COVID-19? *
Have you tested for COVID-19? *
Have you been tested for COVID-19 and are awaiting results? *
Have you traveled outside the United States by air or cruise ship in the past 14 days? *
Have you traveled within the United States, by air, bus or train within the past 14 days? *
Do you have a weakened immune system? *
Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy? *
Do you take steroids for any conditions? Examples of common steroids are Cortisone, Prednisone, Methylprednisone. Contact your physician or our office if not sure. Also, answer YES if unsure. *
Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, or psoriasis? *
Do you have diabetes? *
If so, do you have to take insulin injections?
Do you have asthma or COPD? *

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