Covid-19 Patient Screening Form

Notes for Q1 to Q9

If patient answers "yes" to either question on shortness of breath or coughing, or answers yes to any combination of two other symptoms and the patient does not need emergency care, consider not scheduling or seeing the patient until symptoms resolve or until patient can provide proof they are not infectious for COVID- 19. The doctor may want to seek additional information from the patient regarding symptoms.

Q1. Do you have a fever or above-normal temperature (>100 degree F)? Take temperature at appointment.

Q2. Are you experiencing shortness of breath or having trouble breathing?

Q3. Do you have a dry cough?

Q4. Do you have a runny nose?

Q5. Have you recently lost or had a reduction in your sense of smell or taste?

Q6. Do you have a sore throat?

Q7. Are you experiencing chills or repeated shaking with chills?

Q8. Do you have unexplained muscle pain?

Q9. Do you have a headache?

Notes for Q10

If "yes" and patient does not need emergency care, do not see patient unless it has been more than 7 days since symptoms first appeared and 3 days of no fever without use of fever-reducing medication.

Q10. Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?

Notes for Q11

If yes, ask for date of last contact with COVID-positive patient and set appointment time for more than 14 days later, unless the patient needs emergency care.

Q11. Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?

Q12. Have you been tested for COVID-19 in the last 14 days? If "no," proceed skipping next question.

Notes for Q12 (a)

If positive, determine if patient needs emergency care.If not an emergency, schedule patient to be seen when it has been more than 7 days since symptoms first appeared and 3 days of no fever without use of fever-reducing medication

Q12 (a). If yes, what is the result of the testing?

If negative, proceed to next question.

If still waiting on results, schedule appointment after results are known.

Notes for Q13

If yes, determine if patient traveled to an area where COVID-19 cases are high. Determine if patient followed physical distancing precautions and wore a mask while in public. Use professional judgement when determining whether to proceed with the appointment.

Q13. Have you traveled more than 100 miles from your home in the last 14 days?

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