PRE-APPOINTMENT

IN-OFFICE

Date:      

Date:      

Do you/they have fever or have you/they felt hot or feverish recently
(14-21 days)?

☐ Yes    ☐ No

☐ Yes    ☐ No

Are you/they having shortness of breath or other difficulties breathing?

☐ Yes    ☐ No

☐ Yes    ☐ No

Do you/they have a cough?

☐ Yes    ☐ No

☐ Yes    ☐ No

Any other flu-like symptoms, such as gastrointestinal upset, headache
or fatigue?

☐ Yes    ☐ No

☐ Yes    ☐ No

Have you/they experienced recent loss of taste or smell?

☐ Yes    ☐ No

☐ 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

☐ Yes    ☐ No

Is your/their age over 60?

☐ Yes    ☐ No

☐ Yes    ☐ No

Do you/they have heart disease, lung disease, kidney disease,
diabetes or any auto-immune disorders?

☐ Yes    ☐ No

☐ Yes    ☐ No

Have you/they traveled in the past 14 days to any regions affected
by COVID-19? (as relevant to your location)

☐ Yes    ☐ No

☐ Yes    ☐ No