Patient Screening Form

Patient Name *

Date *

It is important to closely monitor your health and the health of those you care for to help prevent the spread of COVID-19 and other illnesses like the flu.

1. Do You Feel Sick? *

Yes

No

2. In the past 48 hours, have you had, or are you currently experiencing;

Cough (New or Worsening) *

Yes

No

OR two or more of the following symptoms (new or worsening);

Fever (i.e. chills/sweats) *

Yes

No

Sore Throat *

Yes

No

Runny nose/nasal congestion *

Yes

No

Headache *

Yes

No

If yes, go home or stay home as noted above. Follow Public Health instructions for testing and isolation.

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COVID-19 Patient Screening