Transcription of COVID-19 PATIENT SCREENING QUESTIONNAIRE
1 COVID-19 PATIENT SCREENING QUESTIONNAIRE PATIENT Name :_____ Today s Date:_____ Visitor Name :_____ Today s Date:_____ SCREENING QUESTIONS YES NO Do you have a fever or felt feverish lately? Chills? Do you have a cough? Shortness of breath? Do you have any muscle aches or pains? Do you have any new onset of headaches or sore throat? Do you have any other flu like symptoms? Do you have any recent loss of taste or smell? Have you experienced any recent GI upset or diarrhea? Have you been in contact with anyone that has tested positive for COVID-19 recently? Have you traveled to any hot spots affected by COVID-19 in the last 14 days? Have you ever been tested for COVID-19 ? If yes what were the results? Have you been diagnosed with COVID-19 ? If yes , when? Have you received the COVID-19 Vaccine? Which Type? When did you receive it? Please give covid Card to copy for your medical records
