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COVID-19 Prescreening Checklist for Dr. C. Bakala Patients

Please review carefully. If you answer yes to any of the questions listed below, please contact Dr. C. Bakala’s office immediately for further instructions. If you feel you may have COVID-19 symptoms, please contact your family physician and/or dial 811.

SYMPTOM WELLNESS CHECK

1. Have you experienced any of the following symptoms within the last 14 days?

  • Fever or feeling feverish
  • New cough
  • Shortness of breath
  • Flu-like symptoms
  • Fatigue
  • Nausea
  • Diarrhea
  • Chills or shaking with chills
  • Muscle pain
  • Headache
  • Sore throat
  • Loss of taste or smell
  • Rash

2. Have you been diagnosed with or suspected of having COVID-19?

YES / NO

3. Have you been tested for Coronavirus or COVID-19?

YES / NO

4. Have you had an antibody test for COVID-19?

YES / NO

FAMILY AND CLOSE CONTACTS

1. Are any of your family members or close contacts currently sick or experiencing fever,
cough, shortness of breath or flu-like symptoms listed above? YES NO

2. Have any of your family members or close contacts been diagnosed with COVID-19?

YES / NO

RECENT TRAVEL

1. Have you or your family or close contacts travelled to the US or Internationally in the past 14 days?

YES / NO

COVID-19 office visit protocols are as follows:

  • All patients are to arrive on time not early and only one family member is permitted to accompany you.
  • Family members are only permitted in the office if absolutely necessary we ask they wait in the car.
  • All patients and persons entering the office are required to wear a mask.
  • NO food and Drink are permitted. Please complete any forms sent to you prior to your appointment.