Smart Eyes COVID-19 Questionnaire

Thank you for choosing SMART EYES where your health and safety is our primary focus. The AAO, AOA and other ophthalmology and optometry specific sources continue to share and update information regarding patient care, signs, symptoms and the ongoing efforts to understand and control the spread of COVID-19. To help protect our patients and staff against the spread of COVID-19, please answer the following questions:

Name*

First Last

Date of birth*

Have you or anyone in your household had a fever in the last three (3) days, respiratory symptoms (cough and shortness of breath), flu-like symptoms or have been in contact with anyone with a confirmed case of COVID-19?*

Yes
No

Other than healthcare professionals working in patient care, are you currently providing care for anyone how has been diagnosed with COVID-19, had a fever, cough, difficulty breathing or flu-like symptoms in the last 2 weeks?*

Yes
No

Have you traveled internationally in the last 2 weeks?*

Yes
No

Are you or anyone in your household under voluntary or involuntary quarantine in the last 2 weeks?*

Yes
No

Have you or anyone in your household traveled to an area with community spread of COVID-19 in the last 14 days?*

Yes
No

We are practicing all preventative measures put forth by the Centers for Disease Control, including the use of alcohol and bleach -based disinfectants that are commonly used by Optometrists and Ophthalmologists to disinfect our instruments and office furniture. The same disinfection practices already used to prevent office-based spread of viruses are happening before and after every patient encounter. We appreciate your understanding of our new social distancing protocols at this time.

Date*

Signature*