Patient Name

First Last

Date of Birth

Have you tested positive for Covid 19?*

Yes
No

Date*

have you had a follow up negative test result?*

Yes
No

Date*

Please bring a copy of the negative test report to your exam appointment.

In order to keep our patients and staff healthy, if you are experiencing, or have recently experienced flu-like symptoms including but not limited to fever, cough, shortness of breath, sore throat, or rash, we ask that you please re-schedule your appointment no sooner than 14 days out.

Face coverings are required by law. Optix protocol requires that you wear a face covering at all times while in the office.

COVID-19 Pre-Screening Questionnaire*

The only way to confirm if you have COVID-19 is to get tested for it. However, we can work together to help minimize the risks of further spreading COVID-19. Please fill out this questionnaire to help us understand how we can prepare for your visit.

Pre-Screening Questions:

1. Have you recently traveled to an area of high-risk for COVID-19?

Yes
No

2. Have you been around someone who recently traveled to a high-risk area and is also sick?

Yes
No

3. Have you been around someone who is known to have coronavirus (COVID-19)?

Yes
No

4. Have you been told by a health official that you may have been exposed to the virus?

Yes
No

5. Have you had a fever recently?

Yes
No

6. Do you have a cough?

Yes
No

7. Do you have any of these? - Fatigue / Body Aches

Yes
No

8. Are you feeling mild to moderate shortness of breath or mild to moderate difficulty breathing?

Yes
No

9. Are you experiencing symptoms that feel like a life-threatening medical emergency?

Yes
No

For example: Severe shortness of breath and difficulty, breathing, Crushing chest pain, Loss of consciousness, Slurred speech,

10. COVID-19 can affect the elderly or the very young more seriously than others. How old are you?

Age

11. Do you have any of the following?

Please select all that apply

High blood pressure
Diabetes
Heart Disease
Lung Disease
Kidney Disease
Liver Disease
None of the above

12. COVID-19 can affect people who have weaker immune systems from things like chemotherapy, HIV/AIDS, organ transplant, being pregnant, or prolonged steroid use. Do you have a weakened immune system from a known cause?

Yes
No

COVID-19 SCREENING FORM

Please bring a copy of the negative test report to your exam appointment.

COVID-19 Pre-Screening Questionnaire*

Optix Hours: