COVID-19 Patient Screening Form

Northwest Suburban Pediatrics

Please correct the errors described below.

Purpose: The purpose of this form is to screen all patients and their households for COVID19 symptoms and exposures prior to coming to scheduled appointments at Northwest Suburban Pediatrics.

Today’s date:

Patient's Name:

Patient’s date of birth:

Person Completing Form:

Relation to Patient:

Please complete the following screening questions for all patients and their households. Answer all questions unless otherwise indicated.

1) Has the patient or anyone in the household been confirmed or suspected to have Covid-19 in the past 10-14 days?

Yes No

2) Has the patient or anyone in the household been identified as a close contact of a person confirmed or suspected to have Covid-19 in the past 10-14 days?

Yes No

3. Does the Patient or anyone in the household have any of the following symptoms now or in the past 2 weeks: (Check all that apply)

New onset of Cough

Fever to 100.4 or higher or chills

Shortness of breath

Fatigue from an unknown cause

New onset of muscle or body aches

New onset of moderate to severe headaches

New loss of taste or smell

New onset of sore throat

New onset of congestion or runny nose

Nausea or vomiting

Diarrhea

Abdominal Pain from unknown case

None

4) Have you or anyone in your household traveled internationally in the past 10-14 days?

Yes No

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