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Eye Health Solutions Intake Form
admin
2020-05-20T23:18:05+00:00
Eye Health Solutions patient intake form
Patient Advisory and Acknowledgment Receiving Eye and Vision Care During the COVID-19 Pandemic
Dear Patient: You have come to our office for evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following: While our office complies with Kentucky and CDC infection control guidelines to prevent the spread of COVID-19, we cannot make any guarantees, Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. In order to reduce the risk of spreading COVID-19, we are asking you a number of screening questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?
*
Yes
No
HAVE YOU BEEN EXPOSED TO SOMEONE WITH COVID-19 IN THE LAST 2 WEEKS?
*
Yes
No
HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?
*
Yes
No
DO YOU HAVE A FEVER?
*
Yes
No
DO YOU HAVE A COUGH?
*
Yes
No
DO YOU HAVE A RUNNY NOSE?
*
Yes
No
DO YOU HAVE A SORE THROAT?
*
Yes
No
ARE YOU HAVING DIARRHEA?
*
Yes
No
ARE YOU SWEATING MORE THAN NORMAL?
*
Yes
No
HAVE YOU HAD A RECENT CHANGE IN APPETITE?
*
Yes
No
ARE YOU HAVING HEADACHES?
*
Yes
No
ARE YOU FATIGUED?
*
Yes
No
Name
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Last
Signature
Date
Date Format: MM slash DD slash YYYY
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