Pre-Treatment Screening Form

Do you/they have fever or have you/they felt hot or feverish recently
(14-21 days)?

Yes No

Are you/they having shortness of breath or other difficulties breathing?

Yes No

Do you/they have a cough?

Yes No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes No

Have you/they experienced recent loss of taste or smell?

Yes No

Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes No

Is your age over 60?

Yes No

Do you/they have heart disease, lung disease, kidney disease,
diabetes or any auto-immune disorders?

Yes No

Have you/they traveled in the past 14 days to any regions affected
by COVID-19? (as relevant to your location)

Yes No