COVID - 19 CLIENT SCREENING FORMPlease complete the following form so it can be added to your current records Consultation form Covid-19 Form Name * First Name Last Name Date MM DD YYYY Have you been diagnosed with confirmed or suspected COVID- 19 infection in the last 14 days? * Yes No Do you have a fever or have you felt hot or feverish recently? (14-21 days) * Yes No Are you having shortness of breath or other difficulties breathing? * Yes No Do you have a cough? * Yes No Do you have any other flu – like symptoms, such as gastrointestinal upset, headache or fatigue? * Yes No Have you been in contact with any confirmed COVID -19 patients or anyone exhibiting Covid like symptoms in the last 14 days? * Yes No Have you been advised by a doctor to self-isolate in last 14 days? * Yes No I agree that all of the information provided is accurate * If under 16, a parent or guardian must tick this box. Option One Option Two Thank you for filling out the Covid-19 Screening form.