Novel Coronavirus Screening 2020 Questionnaire
2019 Novel Coronavirus Screening 2020 Questionnaire
Patient/Vistor Name:_____________________________________DOB:___________________
Please circle YES or NO to the following questions:
- Have you and/or anyone accompanying you today traveled outside of the U.S.A. in the last 14 days?
YES NO
- Have you and/or anyone accompanying you today been in close contact with a person known to have 2019 Novel Coronavirus?
YES NO
- Do you and/or anyone accompanying you today currently have a fever or any respiratory symptoms such as a cough or shortness of breath?
YES NO
If answered yes to any of the above:
Name the person:__________________________________Phone #:____________________________
Dates of Travel & Location:______________________________________________________________
Signature of person completing this questionnaire:____________________________________________
Relationship to patient/minor (if applicable):___________________________Date:_________________
Nurse Assessment: _____________________________________________________________________
Temp:__________________________Additional Vitals (if needed):______________________________
Additional Assessment needed? Yes / No
Nurse:_______________________________________Date/Time:_______________________________
