COVID-19 Pre-Screening Questionnaire

COVID-19 Pre-Screening Questionnaire

Name
First Last
Date
Date Format: MM slash DD slash YYYY
Envision Optique is firmly committed to protecting our patients and staff from Covid-19. While local restrictions are being eased, we are maintaining guidelines for social distancing, protective masks, and reduced traffic while in the office. Additionally, we are measuring no-touch body temperature and dispensing hand sanitizer upon arrival. Finally, we are asking all our patients to fill out this short questionnaire.

Please Note: Due to restricted scheduling, we are strictly enforcing our Broken Appointment Policy.

(We require 24Hr. notice of changes to confirmed appointments, subject to $50 charge)
1. Have you recently traveled to an area of high-risk for COVID-19?
- Yes
- No
2. Have you been around someone who is known to have COVID-19 within the last 30 days?
- Yes
- No
3. Have you been told by a health official that you may have been exposed to the virus?
- Yes
- No
4. Have you had a fever recently, or do you think you have a fever? (We will measure your temperature upon arrival)
- Yes
- No
5. Do you now have, or have you recently had an unusual cough?
- Yes
- No
6. Do you have any unusual fatigue or body aches, loss of taste or smell?
- Yes
- No
7. Are you feeling unusual shortness of breath or difficulty breathing?
- Yes
- No
8. Are you experiencing any symptoms that feel like a life-threatening medical emergency such as crushing chest pain, loss of consciousness, or slurred speech?
- Yes
- No
9. Do you have any current medical conditions such as high blood pressure, diabetes, or a heart condition?
- Yes
- No
10. COVID-19 can affect people who have weaker immune systems from things like chemotherapy, HIV/AIDS, organ transplant, being pregnant, or prolonged steroid use. Do you have a weakened immune system from a known cause?
- Yes
- No
Thank-you for your cooperation during this difficult time!