COVID-19 PRE-SCREENING PATIENT 1 NAME* First Last DATE OF SERVICE* MM slash DD slash YYYY Has the patient or anyone in the household had or currently have any of the following in the last 21 days:Fever* Yes No Shortness of breath* Yes No Cough* Yes No Flu-like symptoms* Yes No GI upset* Yes No Headache* Yes No Fatigue* Yes No Experienced the loss of taste or smell* Yes No Has the patient or anyone in the household been in contact with anyone confirmed positive for COVID-19?* Yes No Does the patient have any significant condition such as heart disease, lung disease, kidney disease, diabetes, or any autoimmune disorders?* Yes No Can the patient swish and spit?* Yes No PATIENT 2 NAME First Last Fever Yes No Shortness of breath Yes No Cough Yes No Flu-like symptoms Yes No GI upset Yes No Headache Yes No Fatigue Yes No Experienced the loss of taste or smell Yes No Has the patient or anyone in the household been in contact with anyone confirmed positive for COVID-19? Yes No Does the patient have any significant condition such as heart disease, lung disease, kidney disease, diabetes, or any autoimmune disorders? Yes No Can the patient swish and spit? Yes No CommentsThis field is for validation purposes and should be left unchanged.
