(847) 498-4770

510 N. Western Ave

Lake Forest, IL 60045

(847) 283-0800

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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 The Optometrists of the North Shore

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 Canada 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)

Request An Appointment

1544 Shermer Road
Northbrook, IL 60062
(847) 498-4770

Mon

9:00 - 7:00

Tue

9:00 - 6:00

Wed

9:00 - 5:00

Thu

9:00 - 7:00

Fri

9:00 - 5:00

Sat

8:00 - 2:00

Sun

Closed

510 N. Western Ave
Lake Forest, IL 60045
(847) 283-0800

Mon

9:00 - 5:00

Tue

9:00 - 5:00

Wed

9:00 - 5:00

Thu

9:00 - 5:00

Fri

9:00 - 5:00

Sat

9:00 - 2:00

Sun

Closed

Lake Forest Office 510 N. Western Ave Lake Forest, IL 60045 Phone: (847) 283-0800 Fax: (847) 283-0782

Northbrook Office 1544 Shermer Road Northbrook, IL 60062 Phone: (847) 498-4770 Fax: (847) 498-6909

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