COVID-19 Risk Assessment Questionnaire

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Prior to coming into the office, you will be asked the following questions. If you reply yes to any of the questions, we ask that reschedule your appointment to a later date. You will also be asked these questions at your appointment when you come in to the office.

Email *

Patient Name (First and Last): *

Patient's guardian name, if applicable (First and Last):

Have you experienced any of the following symptoms in the past 48 hours? (Check all that apply) *

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

None of the above

Required

Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19? *

Yes

Have you been in close physical contact in the last 14 days with: *

Anyone who is known to have laboratory-confirmed COVID-19?

Anyone who has any symptoms consistent with COVID-19?

None of the above

Are you currently waiting on the results of a COVID-19 test? *

Yes

I consent to treatment at Denver Vision Therapy under the following conditions: Patient and any guardians accompanying patient will wear a mask for the duration of the visit, wash hands thoroughly or sanitize hands upon arrival, and allow the DVT staff to take the temperature of the patient and guardian with a touch-less forehead thermometer. *

I agree

Required

We are limiting the number of people who are in our office. For pediatric patients, only one parent is permitted, and no siblings unless absolutely necessary. For vision therapy sessions, parents may be asked to wait in their car to limit the number of people in the reception room. If you are parent of a pediatric patient, you are not permitted to leave the premise during the appt in case of an emergency. For adult patients, only family members who must accompany the patient for medical reasons will be permitted. *

I agree

Required

If any of the above answers change prior to my appointment, or if I test positive for COVID-19 within 10 days after my appointment at DVT, I agree to notify DVT staff immediately. *

I agree

Required

Today's Date *

YYYY

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