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:_______________________________


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