Patient Screening Form for Covid-19
Infection control has always been a top priority for our patients and staff.  Kindly complete this questionnaire and consent form.  Positive responses to any of these questions would likely indicate a deeper discussion with Dr. Kimi Caswell.    
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Patient's FIRST & LAST NAME: *
Does the patient have a fever or have they felt hot or feverish recently (14-21 days)? *
Required
Is the patient experiencing shortness of breath or other difficulties breathing? *
Required
Does the patient have a cough? *
Required
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *
Required
Has the patient experienced recent loss of taste or smell? *
Required
Has the patient been 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 this appointment. *
Required
Does the patient have heart disease, lung disease, diabetes or any auto-immune disorders? *
Required
Has the patient traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) *
Required
If answered Yes to any of the above, please explain.
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