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

 

 

Nurse:_______________________________________Date/Time:_______________________________

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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We want you to get the most out of your consultation. If at all possible, it is best to make arrangements for small children to stay home rather than having them join us for your appointments.