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Dr. Joyce Lockwood
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COVID-19 UPDATE
Patient Screening Form
Patient screening form
Have you/they been diagnosed with COVID-19 or are you/they in contact with any confirmed COVID-19 positive patients?
*
Yes (pre-appointment)
No (pre-appointment)
Yes (in-office)
No (in-office)
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
*
Yes (pre-appointment)
No (pre-appointment)
Yes (in-office)
No (in-office)
Have you/they travelled in the past 14 days to any regions affected by COVID-19?
*
Yes (pre-appointment)
No (pre-appointment)
Yes (in-office)
No (in-office)
Are you/they having shortness of breath or other difficulties breathing?
*
Yes (pre-appointment)
No (pre-appointment)
Yes (in-office)
No (in-office)
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
*
Yes (pre-appointment)
No (pre-appointment)
Yes (in-office)
No (in-office)
Have you/they experienced recent loss of taste or smell?
*
Yes (pre-appointment)
No (pre-appointment)
Yes (in-office)
No (in-office)
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
*
Yes (pre-appointment)
No (pre-appointment)
Yes (in-office)
No (in-office)
Name:
*
Is your/their age over 60?
*
Yes (pre-appointment)
No (pre-appointment)
Yes (in-office)
No (in-office)
Do you/they have a cough?
*
Yes (pre-appointment)
No (pre-appointment)
Yes (in-office)
No (in-office)
Thank you for completing this form.
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