| Before Appointment: Yes | Before Appointment: No | In-office: Yes | In-office: No |
Have you tested positive for COVID-19 or are you awaiting results for a COVID-19 test? | | | | |
Do you have any of the following: Cold or flu-like symptoms Fever, Cough, Sore throat, Headache, Fatigue, Abdominal pain or Diarrhea? | | | | |
Are you having shortness of breath or other difficulties breathing? | | | | |
Have you experienced recent loss of taste or smell? | | | | |
Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days? | | | | |
Are you, or have you in the last 14 days, in contact with any confirmed COVID-19 positive patients? | | | | |
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? | | | | |
Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? | | | | |