Do you/they have fever or have you/they felt hot or feverish recently?
Yes
No
Are you/they having shortness of breath or other difficulties breathing?
Yes
No
Do you/they have a cough?
Yes
No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Yes
No
Have you/they experienced recent loss of taste or smell?
Yes
No
Are you/they 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 elective treatment.)
Yes
No
Is your/their age over 60?
Yes
No
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Yes
No
Have you/they traveled in the past 14 days?
Yes
No
Patient Name