Patient Screening Form Name* First Last Date of Birth MM slash DD slash YYYY Phone*Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?* Yes No Are you/they experiencing shortness of breath or other difficulties breathing?* Yes No Do you/they have a cough or a sore throat?* Yes No Any other flu-like symptoms, such as gastrointestinal upset, nausea, diarrhea, headache or fatigue?* Yes No Have you/they experienced recent loss of taste or smell?* Yes No Are you/they in contact with any confirmed COVID-19 positive patients?* Yes No • 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?* Yes No Positive responses to any of these would likely indicate that your appointment will be postponedPATIENT/LEGAL GUARDIAN SIGNATURE*Date MM slash DD slash YYYY