COVID-19 Screening Form

The following questions will help us determine if a patient or family has COVID-19, symptoms of or exposure to COVID-19 or has a positive, probable or pending diagnosis.

If you answer YES to any of these questions, please contact the office as we will need to reschedule your appointment. Thank you! 

Thank you for helping us keep you safe!
 

 
 
 
In the past 14 days, have you or anyone in your household spent more than 24 hours outside of Illinois, specifically in a state on the Chicago Travel Order

Have you or anyone in your household been diagnosed with or suspected of COVID-19 in the last 14 days?

In the past 14 days, has any member of the household been exposed to someone who has been diagnosed with COVID-19 or had a positive or pending result for COVID-19?

Is anyone in the household experiencing any fever, cough, shortness of breath, runny nose, sore throat, congestion, new onset of vomiting or diarrhea, or complete loss of taste or smell?