Pre Appointment Screening Form

Date:*

Date

Name*

First NameLast Name

AGE*

Mobile number*

Address*

CityState

Pincode

Have you previously been diagnosed with COVID-19, or do you think you’ve had/have COVID-19?*

YES.NO.I currently have symptoms and am waiting for a test

If you have had COVID-19, when were you confirmed negative?*

24 hours agotoday10 days after testingNOT applicable

Do you currently have (or have you experienced) any of the following symptoms in the past 21 days:

FEVER*

YESNO

SORE THROAT*

YESNO

HEAD ACHE*

YESNO

TROUBLE BREATHING/SHORTNESS OF BREATH/CHEST TIGHTNESS*

YESNO

CHILLS*

YESNO

MUSCLE PAINS*

YESNO

ALTERED TASTE OR SMELL*

YESNO

DRY COUGH*

YESNO

Fatigue (feeling tired)*

YESNO

Are you in contact with anyone who has been sick and/or confirmed to be COVID-19–positive?*

YESNO

Have you travelled by commercial airline, bus, or train within the past 14 days*

YESNO

In the past 14 days have you traveled to any regions affected by COVID-19?*

YESNO

IF YES DESCRIBE

Some medical conditions have been associated with more severe COVID-19 disease. The following questions are an attempt to determine your risk

DIABETES*

YESNO

ASTHAMA / respiratory problems?*

YESNO

High Blood Pressure*

YESNO

Are there any other conditions you would like to report?

I understand the government recommends social distancing of at least 6 feet for a period
of 14 days to anyone who has shown symptoms or tested positive.

I verify that I have not travelled outside of India in the past 14 days to countries that have
been affected by COVID-19.

I verify that I have not travelled domestic within India by commercial airline, bus, or train
within the past 14 days

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to treatment completed during the COVID-19 pandemic. If I hide my facts and relevant details and because of my knowing or unknowing behaviour or action the clinic staff gets infected, I may be held responsible for appropriate compensation in the court of law

Patients Photo

COVID-19 Screening Form

PREAPPOINTMENT CHECK