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Dr. Edward C. Appelman, O.D.
Dr. Amy Mackey Carenza, O.D.
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Patientforms
Covid19screeningquestionnaire.Aspx
COVID-19 Screening Questionnaire
Patient Full Name
Patient Date of Birth (mm/dd/yyyy - ex: 02/06/1999)
The health and welfare of our patients and staff is our top priority.
Please complete the COVID-19 screening questionnaire below to confirm your appointment for optometric services at
Appelman Eye Associates
Required Screening Questions:
1. Do you have any of the following
new or worsening
symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.
Questions
Yes/No/?
Fever or Chills
Yes
No
Difficulty breathing or shortness of breath
Yes
No
Cough
Yes
No
Sore throat/trouble swallowing
Yes
No
Runny nose/stuffy nose or nasal congestion
Yes
No
Decrease or loss of smell or taste
Yes
No
Nausea, vomiting, diarrhea, abdominal pain
Yes
No
Not feeling well, extreme tiredness, sore muscles
Yes
No
2. Have you traveled outside of the country in the past 14 days?
Yes
No
3. Have you had close contact with a confirmed or probable case of COVID-19?
Yes
No
If you answered yes to any of the questions 1-3, please reschedule your appointment and contact your health care provider.
Signature of patient / legal guardian (type your name)
Captcha:
*
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