Patient Name:
Phone Number:
Email Address:
Pre-Appointment
In-Office
Date:
Date:
Do you/they have fever or have you/they felt hot or feverish, had chills or repeated shaking with chills, or had muscle pain recently (14-21 days)?
Yes No
Are you/they having shortness of breath or other difficulties breathing?
Yes No
Do you/they have a cough?
Yes No
Any other flu-like symptoms, such as gastrointestinal upset, headache, fatigue, nasal congestion, or sore throat?
Yes No
Have you/they experienced recent loss of taste or smell?
Yes No
Are you/they in contact with any confirmed COVID-19 positive patients?Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Yes No
Is your/their age over 60?
Yes No
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Yes No
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
Yes No
Are you allergic to Iodine or Shellfish
Yes No
