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NOVEL CORONAVIRUS DISEASE (COVID-19) SCREENING QUESTIONNAIRE

Do you have a fever or have you felt hot or feverish recently (14-21 days)?

Are you having shortness of breath or other difficulties breathing?

Do you have a cough?

Do you have any other flu-like symptoms, such as chills, muscle pain, sore throat, gastrointestinal upset, headache or fatigue?

Have you experienced recent loss of taste or smell?

Have you been in close contact with another person who has been diagnosed with/under investigation for COVID-19?

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you been diagnosed with Covid-19?

Have you participated in any large group events such as Rallies, Marches or other gatherings in the past 14 days?

Contact your primary physician or public health department as soon as possible to determine if you should be seen or tested.

Visit https://www.naccho.org/membership/lhd-directory for information on how to contact your local health department and https://www.cste.org/page/EpiOnCall for information on how to contact your state health department.

First Name

Last Name

Date Of Birth

Signature of Patient or Legal Guardian

Date