COVID-19 Screening Questionnaire

Office
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 Focus Vision

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)



2115 S. HACIENDA BLVD.
HACIENDA HEIGHTS, CA 91745
Call (626) 330-4115
Map it!
Mon
9:00 - 6:00
Tue
9:00 - 6:00
Wed
9:00 - 6:00
Thu
Closed
Fri
9:00 - 6:00
Sat
9:00 - 5:00
Sun
Closed
500 N. ATLANTIC BLVD. UNIT 151
MONTEREY PARK, CA 91754
Call (626) 458-2020
Map it!
Mon
10:00 - 5:00
Tue
10:00 - 5:00
Wed
10:00 - 5:00
Thu
10:00 - 5:00
Fri
10:00 - 5:00
Sat
Closed
Sun
Closed
Hacienda Heights Office 21115 S. Hacienda BLVD Hacienda Heights, CA 91745 Phone:
Monterey Park Office 500 N. Atlantic Blvd. Unit 151 Monterey Park, CA 91754 Phone:

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