Novel Coronavirus Screening 2020 Questionnaire  

Serving Phoenix, Scottsdale, Tempe, Gilbert, Chandler, Glendale, Mesa And Surrounding Areas In Arizona

2019 Novel Coronavirus Screening 2020 Questionnaire


               Patient/Vistor Name:_____________________________________DOB:___________________


Please circle YES or NO to the following questions:


  • Have you and/or anyone accompanying you today traveled outside of the U.S.A. in the last 14 days?

YES                                       NO

  • Have you and/or anyone accompanying you today been in close contact with a person known to have 2019 Novel Coronavirus?


YES                                       NO


  • Do you and/or anyone accompanying you today currently have a fever or any respiratory symptoms such as a cough or shortness of breath?

YES                                       NO


If answered yes to any of the above:

Name the person:__________________________________Phone #:____________________________

Dates of Travel & Location:______________________________________________________________


Signature of person completing this questionnaire:____________________________________________

Relationship to patient/minor (if applicable):___________________________Date:_________________


Nurse Assessment: _____________________________________________________________________

Temp:__________________________Additional Vitals (if needed):______________________________

Additional Assessment needed?  Yes / No




American Board Certified Plastic Surgeon, Certified by the Royal College of Physicians and Surgeons of Canada at

Dr. Mahabir’s reputation as a cosmetic facial and plastic surgeon in the Phoenix and Scottsdale area has been built on his ability to achieve natural results and a more refreshed look for his patients without being “overdone”. He takes a particular interest in breast surgery and helping breast cancer patients post-mastectomy.

Board Certified Plastic Surgeon at

Dr. Gawley is one of the premiere plastic surgeons in the Scottsdale and Phoenix area. He specializes in cosmetic and reconstructive surgery of the breast, body, and face. Dr. Gawley combines his extensive training and state-of-the-art technology to provide his patients with personalized care and natural results.

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