PATIENT HEALTH QUESTIONAIRE

PRIOR TO THE START OF MY VISIT, I CONFIRM THAT:

I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past 14 days.

I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks.

I have not traveled outside of my immediate daily routine for the past two weeks.

I do not have a cough, fever, shills, shortness of breath, or loss of taste or smell.

If I begin to show symptoms of COVID-19 within the two weeks, I will contact my audiologist at All About Hearing Inc. (432-689-2220)

I will follow all posted office rules to wear a mask and keep those around me safe

Patient Name:

First NameLast Name

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