Name

First Name Last Name

Phone Number

Appointment Date & Time

1. Are you experiencing or have you experienced any of the following within the last two weeks:

Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
Severe chest pain
Having a very hard time waking up
Feeling confused Losing consciousness

YES NO

2. Are you experiencing or have you experienced any of the following within the last two weeks:

Shortness of breath at rest
Inability to lie down because of difficulty breathing
Chronic health conditions that you are having difficulty managing because of difficulty breathing
High grade fever with rigors
Loss of smell or taste

YES NO

3. Are you experiencing any of the following: Fever, Cough, Sneezing or other flu- like symptoms, Sore throat, Mild shortness of breath, Runny nose, Post-nasal drip?

YES NO

4. Have you travelled to any countries within the last 14 days?

YES NO

5. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill (cough, fever, sneezing, or sore throat)?

YES NO

6. Did you have close contact with a person who travelled in the last 14 days who has become ill (cough, fever, sneezing, or sore throat)?

YES NO

7. Do you have any underlying chronic condition including Diabetes, Hypertension, Chronic heart/ kidney/ liver disease or autoimmune disorder?

YES NO

8. Is your workplace considered high risk?

YES NO

8. Have you taken Advil or Tylenol in the last 24 hours?

YES NO

If you have answered yes to any of these questions please call to discuss possibly rescheduling your appointment

When you arrive at the office, they will be asked to: have your temperature taken; sanitize your hands; answer the questions again; complete a form acknowledging the risk of COVID-19.
Only patients will be allowed to come to the office.

Please wait in their car until your appointment, call the office when you arrive

Please Complete and Submit ASAP.

COVID19 Self Assessment Questionnaire