Patient Safety Check Form

Patient Safety Check Form
Please don't forget to bring the following:
1. ID card with picture
2. Insurance cards
3. Safety checklist form
4. Medical or diagnostic records
5. Wear a mask and face shield
Name
First NameLast Name
Age
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date and Time of Appointment
Reason for Appointment
Name of Physician
First NameLast Name
Emergency Person Name
First NameLast Name
Emergency Person Phone Number
Please enter a valid phone number.
Are you currently taking any medications? If yes, please list them below:
Do you have any allergies? If yes, please identify them below:
Do you have any of the following family medical history?
DiabetesHypertensionKidney diseaseLiver diseaseGlaucomaSeizuresDepressionOther
Do you have any of the following conditions? Select all that apply:
Hearing issuesEye issuesEating disordersUndergoing chemotherapyPregnancy (women)DepressionOther
COVID-19 related questions

COVID-19 Symptoms

	No	Yes
Is your temperature 100.4F or higher?	1	2
Do you have nasal congestion?	3	4
Do you have runny nose?	5	6
Did you lose your sense of taste?	7	8
Did you lose your sense of smell?	9	10
Are you having difficulty breathing?	11	12
Do you have a cough?	13	14
Do you have a sore throat?	15	16
Are you having headaches?	17	18
Do you feel body weakness?	19	20
Do you have diarrhea?	21	22

Have you been tested positive for COVID 19 within the last 14 days?
YesNo
Do you have any travel history within the last 7-14 days?
YesNo
Have you been in close contact or proximity to someone who’s been tested positive for COVID 19 within the last 14 days?
YesNo
Are you currently waiting for a COVID 19 test result within the last 7-14 days?
YesNo
Do you have a family or household member who is exposed of COVID-19?
YesNo
Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

COVID-19 related questions