COVID-19 Questionnaire Only COVID-19 Pre-Screening Questionnaire Only Name First Last Date Month Day Year 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!