Patient Screening Form Name* First Last Date of Birth Date Format: MM slash DD slash YYYY Phone*Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YesNoAre you/they experiencing shortness of breath or other difficulties breathing?*YesNoDo you/they have a cough or a sore throat?*YesNoAny other flu-like symptoms, such as gastrointestinal upset, nausea, diarrhea, headache or fatigue?*YesNoHave you/they experienced recent loss of taste or smell?*YesNoAre you/they in contact with any confirmed COVID-19 positive patients?*YesNo• Patients who are well but who have a sick family member at home with COVID-19 should consider postponing office visit. Have you/they traveled outside the country in the past 14-21 days?*YesNoPositive responses to any of these would likely indicate that your appointment will be postponedPATIENT/LEGAL GUARDIAN SIGNATURE*Date Date Format: MM slash DD slash YYYY