Pre-Visit Parent/Family Screening Form (MANDATORY) Pre-Visit Screening Patient Name * Email Address * Has anyone had a fever or have felt hot or feverish recently (14-21 days)? * Yes No Is anyone having shortness of breath or other difficulties breathing? * Yes No Has anyone had a cough? * Yes No Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? * Yes No Has anyone experienced recent loss of taste or smell? * Yes No Has anyone been in contact with any confirmed COVID-19 positive patients? * Yes No Are you over the age of 60? * Yes No Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? * Yes No Has anyone traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) * Yes No Submit