COVID-19 Patient Screening Form PATIENT INFORMATION Patient Name * Date PATIENT SCREENING Vaccination / Testing Have you/they recently been vaccinated for COVID-19? YesNo Have you/they recently received a booster shot for COVID-19? YesNo If yes, when was your/their last shot? Which vaccination did you/they receive? Have you/they recently been tested for COVID-19? YesNo If yes, please specify test date Have you/they tested positive for COVID-19? YesNo If yes, please specify the date of your/their positive test result Within the past 14 days, have you/they had a known exposure to any individual suspected or confirmed to have COVID-19 or who has traveled to a location after which self-quarantine is recommended? YesNo Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Is your/their age over 60? YesNo Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorder? YesNo Within the past 24 hours, have you/they had any of the following symptoms? Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadachesNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrhea Additional notes (optional) SIGNATURE NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. I confirm the information provided is accurate and I consent to electronic signature. I understand this document may be signed electronically for the purposes of validity, enforceability, and admissibility. Name of Patient/Legal Guardian * Date * Electronic Signature (type full name) *
