Learn the facts about COVID-19 The health of you, your family, and your community is our top priority. Take a moment to learn how to protect yourself and prevent the spread of COVID-19.

Phone: (956) 353-6055
Fax: (956) 353-6011
ADMINISTRATOR JOR FLORES, RN/DOPS
Cell: (956) 929-1204
j.flores@physicianpreferred-hhs.com

Patient Screening Form

Based upon CDC data, older adults or those with underlying chronic medical conditions may be most at risk for severe outcomes. Agency personnel should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. Before conducting any scheduled visit with Patient/ Attendant perform COVID-19 phone screening.

	Client	Household Member(s)	Attendant	Office Staff
Do you have a fever defined as a temperature of 100.4 Fahrenheit and above?	YesNo	YesNo	YesNo	YesNo
Do you have any of the following signs or symptoms of a respiratory infection signs or symptoms of COVID-19, including chills, cough, shortness of breath, or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea?	YesNo	YesNo	YesNo	YesNo
Have you had contact in the last 14 days, unless to provide critical assistance in a licensed facility or essential services through the HCSSA, with someone who has a confirmed diagnosis of COVID-19, is under investigation for COVID-19, or is ill with a communicable respiratory illness	YesNo	YesNo	YesNo	YesNo
Have you visited someone with confirmed COVID-19?	YesNo	YesNo	YesNo	YesNo

Attestation of Screening: I attest that I have complied with agency policies to prevent the spread of COVID-19.

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Visit CDC Website for Updates: https://www.cdc.gov/coronavirus/2019-ncov/index.html