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 Advanced Eyecare Professionals P.C.

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)



OFFICE HOURS    
Mon
10:00 - 6:00
Tue
10:00 - 6:00
Wed
9:00 - 2:00
Thu
10:00 - 6:00
Fri
Closed
Sat*
9:00 - 1:00
* By Appointment Only
10320 S Cicero Avenue
Oak Lawn, IL 60453
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(708) 229-2200
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Advanced Eye Care Professionals 10320 S Cicero Avenue Oak Lawn, IL 60453 Phone: (708) 229-2200 Fax: (708) 229-2233

Advanced Eye Care Professionals proudly serves Oak Lawn, IL and the surrounding areas of Beverly, Evergreen Park, Alsip, Worth, Chicago Ridge, Palos Hills, Palos Heights, Orland Park and Chicago.

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