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Health-Screening Questionnaire

Company

The safety of our patients and staff is of utmost importance to Hope Springs. Given the recent COVID-19 outbreak, we ask you answer the following question before your appointment. These are designed to help promote your safety, as well as the safety of our staff and other patients. We are asking the same questions to all practice patients to help ensure everyone’s safety. So that we can ensure that you receive care at the appropriate time and setting, please answer these questions truthfully and accurately. All of your responses will remain confidential. As appropriate, the information you provide will be reviewed you may be provided additional guidance regarding whether any adjustments need to be made to your scheduled appointment.

yn1

Yes No

Have you or a member of your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever, temperature at or greater than 100 degrees Fahrenheit?

yn2

Yes No

Have you or a member of your household tested positive for COVID-19?

yn3

Yes No

Were you or a member of your household advised to self-quarantine for COVID-19 by government officials or healthcare providers?

yn4

Yes No

Have you or a member of your household been advised to be tested for COVID-19 by government officials or healthcare providers?

yn5

Yes No

Have you or a member of your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?

yn6

Yes No

Have you or a member of your household traveled outside the U.S. in the past 30 days?

yn7

Yes No

Have you or a member of your household traveled elsewhere in the U.S. in the past 21 days?

yn8

Yes No

Have you or a member of your household traveled on a cruise ship in the last 21 days?

yn9

Yes No

Are you or a member of your household healthcare providers or emergency responders?

yn10

Yes No

Have you or a member of your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?

yn11

Yes No

Do you have any reason to believe you or a member of your household has been exposed to or acquired COVID-19?

yn12

Yes No

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?

Cient First Name *

Email (Client or Guardian)

Client Last Name *

Signer Name *

Relationship to Client *

Self Parent Legal Guardian

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