Screening Questionnaire Patient Screening Form To be completed prior to appointment.Patient Name* First Last Guardian Name(Required if patient under the age of 18.) First Last Please note the following: Upon arrival to the office, please sanitize your hands. The receptionist will come around to check your temperature and ask the following pre-screening questions again once you are in the office. 1. Do you have a fever or have felt hot or feverish anytime in the last 10 days?* Yes No 2. Do you have any of these symptoms: New or worsening cough? New or worsening shortness of breath? Difficulty breathing? Sore Throat or painful swallowing? Runny nose?* Yes No 3. Have you experienced a recent loss of smell or taste?* Yes No 4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?* Yes No 5. Have you travelled on a airplane in the last 14 days (domestic or international)?* Yes No 6. Is your workplace considered high risk?* Yes No 7. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?* Yes No CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.