COVID-19 Screening Questionnaire

Complete the required screening questions to confirm the patient's appointment for optometric services at Morrison Eye Clinic, S.C..

Required fields

Patient details

Identify the patient completing this screening.

Patient Full Name

Patient Date of Birth

Symptoms

Do you have any of the following new or worsening symptoms or signs? Do not include symptoms that are chronic or related to other known causes or conditions.

Fever or Chills

Difficulty breathing or shortness of breath

Cough

Sore throat / trouble swallowing

Runny nose, stuffy nose, or nasal congestion

Decrease or loss of smell or taste

Nausea, vomiting, diarrhea, or abdominal pain

Not feeling well, extreme tiredness, or sore muscles

Travel and exposure

Answer the following questions about recent travel and contact.

Have you traveled outside of the country in the past 14 days?

Have you had close contact with a confirmed or probable case of COVID-19?

If you answered yes to any screening question: Please reschedule your appointment and contact your health care provider.

Patient acknowledgment

Sign the completed screening questionnaire by typing the patient or legal guardian's name.

Signature of Patient / Legal Guardian

Patient Resources

Everything you need,
right here.

Quick access to appointments, forms, insurance information, eyewear, and contact lens resources.

Contact Lens Center Request Appointment Patient Forms Insurance Info Designer Frames

Patient details

Symptoms

Travel and exposure

Patient acknowledgment

Everything you need,right here.

Everything you need,
right here.