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COVID-19 Screening Questionnaire

Patient Full Name

Patient Date of Birth (mm/dd/yyyy - ex: 02/06/1999)

The health and welfare of our patients and staff is our top priority.

Please complete the COVID-19 screening questionnaire below to confirm your appointment for optometric services at Dempster Eye Center

Required Screening Questions:

1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Questions

Yes/No/?

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, abdominal pain

Not feeling well, extreme tiredness, sore muscles

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

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

If you answered yes to any of the questions 1-3, please reschedule your appointment and contact your health care provider.

Signature of patient / legal guardian (type your name)

Captcha:

Enter Letters/Number you see:

Dempster Eye Care
7174 Dempster St
Morton Grove, IL 60053
(847) 470-1115

OFFICE HOURS

Monday

9:00am - 6:00pm

Tuesday

10:00am - 7:00pm

Wednesday

9:00am - 6:00pm

Thursday

10:00am - 7:00pm

Friday

9:00am - 6:00pm

Saturday

8:30am - 2:30pm