COVID-19 Screening Sheet

Patient/Support Person Name

Today's Date

Day of Appointment

Do you have a COVID-19 diagnosis made or have you had a test confirming you have the SARS-CoV-2 virus within the past 10 days?

Yes No

Do you have a COVID-19 diagnosis made or have you had a test confirming you have the SARS-CoV-2 virus within the past 10 days?

Yes No

Have you shared a household with or been in close contact with someone who was diagnosed with COVID-19 or had a test confirming they have the SARS-CoV-2 virus within the past 14 days?

Yes No

Have you shared a household with or been in close contact with someone who was diagnosed with COVID-19 or had a test confirming they have the SARS-CoV-2 virus within the past 14 days?

Yes No

Do you have a history of travel by airplane within the past 14 days?

Yes No

Do you have a history of travel by airplane within the past 14 days?

Yes No

Do you have a fever?

Yes No

Do you have a fever?

Yes No

Do you have chills?

Yes No

Do you have chills?

Yes No

Do you have repeated shaking/shivering?

Yes No

Do you have repeated shaking/shivering?

Yes No

Do you have a cough?

Yes No

Do you have a cough?

Yes No

Do you have a sore throat?

Yes No

Do you have a sore throat?

Yes No

Do you have shortness of breath or difficulty breathing?

Yes No

Do you have shortness of breath or difficulty breathing?

Yes No

Do you have unusual weakness or fatigue?

Yes No

Do you have unusual weakness or fatigue?

Yes No

Do you have a loss of taste or smell?

Yes No

Do you have a loss of taste or smell?

Yes No

Do you have muscle pain?

Yes No

Do you have muscle pain?

Yes No

Do you have a headache?

Yes No

Do you have a headache?

Yes No

Do you have a runny nose or congestion?

Yes No

Do you have a runny nose or congestion?

Yes No

Do you have diarrhea?

Yes No

Do you have diarrhea?

Yes No

Care deferred and patient appropriately refered if screening elements warrant.

Your information will be encrypted.