COVID‐19 PANDEMIC ‐ PATIENT SCREENING FORM
 
 
 Do you have a fever or have you felt hot or feverish in the last 14 days?
 
 
Are you experiencing shortness of breath or other difficulties breathing?
(other than asthma)
 
 
Do you have a dry cough?
(other than normal seasonal allergies)
 
 
Have you experienced recent loss of taste or smell?
 
 
Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
 
 
Are you in contact with any confirmed COVID-19 positive patients?
 
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