COVID-19 – Patient Screening Patient Name First Last Email Date Month Day Year Do you have any of the following symptoms: fever, cough, shortness of breath, chills, runny nose, stuffy nose, sore throat, nausea, vomiting, and/or diarrhea?* Yes No Have you been exposed to anyone diagnosed with Covid-19 (coronavirus) in the past 4 weeks?* Yes No Have you been diagnosed with COVID-19 (coronavirus) in the past 4 weeks? Yes No Do you have any respiratory problems? (Uncontrolled Asthma, COPD, Bronchitis, etc.)* Yes No Do you have a history of immunosuppression? (Transplant or Chemotherapy)* Yes No If immunosuppressed, did you have: Chemotherapy Transplant Have you been given the OK to proceed with testing by your oncologist? Yes NO If the answer is “YES” to any of the above questions, the patient will be instructed to reschedule their appointment, at least 14 days after their symptoms have resolved, 4 weeks after exposure, or an overseas trip. For chronic conditions or immunosuppressed patients, such as asthma, COPD, bronchitis, etc. patients will be rescheduled once all federal and state restrictions are lifted.Staff Signature First Last
