COVID-19 Questionnaire

COVID-19 Questionnaire

COVID-19 Questionnaire

COVID-19 Questionnaire

COVID-19 Screening Questionnaire

In response to the recent Coronavirus (COVID-19) outbreak and raised pandemic alert status by the World Health Organization (WHO), Optometric Associates, PC is taking precautions to lessen the spread of the virus. All legal guardians and patients must have a screening from completed.

Please review the following self screening criteria:

Has the patient or anyone in the family (household) tested positive for COVID-19?*

Has the patient or anyone in the family (household) tested positive for COVID-19? and are waiting for the result?*

Does the patient or anyone in the family (household) have any of the following respiratory syptoms? Fever, Sore Throat, Cough, Shortness of Breath?*

Has the patient or anyone in the family (household) recently lost your sense of smell or taste?*

Even if you don't currently have any of the above symptoms, has the patient or anyone in the family (household) experienced any of these symptoms in the last 14 days?*

Has the patient or anyone in the family (household) been in contact with someone who has tested positive for COVID-19 in the last 14 days?*

Has the patient or anyone in the family (household) traveled outside the United States by air or cruise ship in the past 14 days?*

Has the patient or anyone in the family (household) traveled outside the United States by air, bus or train within the past 14 days?*

Patients Name(s)*

Date of Birth*

Select Date*

Relationship to Patient*

1 none 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM Closed Closed optometrist # # #