COVID-19 Screening - Park Street Pediatrics

Park Street Pediatrics, LLC

Your child's health isn't 9 to 5
...neither are we ®

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Pre-Screening Questionnaire

Please fill out this form prior to your appointment

We ask all visotors for this information for your safety.

Child's Name

Today's Date

Primary Insurance

Other Insurance

ID Number

Group Number

Subscriber Name

Subscriber DOB

Relationship to Patient

Self Parent/Guardian

Do you have a Secondary Insurance?

Yes No

Secondary Insurance

ID Number

Group Number

Please send photos of the front and back of your insurance card to: pspoffice@pspkids.com

Has your child had a temperature of 100.4°F or greater in the past 24 hours?

Yes No

Has your child taken any fever reducing medications in the past 24 hours?

Yes No

Has your child traveled to a state that is banned in the past 24 hours?

Yes No

Has you had any visitors in the last 2 weeks from a state that is banned?

Yes No

Travel list: https://portal.ct.gov/coronavirus/travel

Does your child have any of the following symptoms?

Loss of Smell or Taste?

Yes No

Sore Throat?

Yes No

Cough?

Yes No

Muscle or Body Aches?

Yes No

Shortness of Breath?

Yes No

Chills?

Yes No

Headache?

Yes No

Fatigue?

Yes No

Congestion/Runny Nose?

Yes No

Nausea/Vomiting?

Yes No

Diarrhea?

Yes No

Loss of Appetite?

Yes No

Placed on quarantine for possible contact with COVID-19?

Yes No

Parent's Name

Tel: (203) 840-7566
FAX: (203) 840-7569

Park Street Pediatrics LLC
7 Park Street
Norwalk, CT 06851

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Park Street Pediatrics, LLC

Your child's health isn't 9 to 5...neither are we ®

Pre-Screening Questionnaire

Tel: (203) 840-7566 FAX: (203) 840-7569

Your child's health isn't 9 to 5
...neither are we ®

Tel: (203) 840-7566
FAX: (203) 840-7569