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Patient Covid-19 Screening Form

Please answer the following questions: Pre-Screening

- Fever

- New onset of cough

- Worsening chronic cough

- Shortness of breath

- Difficulty breathing

- Sore Throat

- Difficulty Swallowing

- Decrease or loss of sense of taste or smell

- Chills

- Headaches

- Unexplained fatigue, malaise, muscle aches (myalgias)

- Nausea, vomiting, diarrhea, abdominal pain

- Pink eye (conjunctivitis)

- Runny nose, nasal congestion without other known cause

- Delirium

- Unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions

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