CORONA VIRUS/COVID-19 SCREENING Name First Last PhonePlease work with us to help protect our patients and our staff. Check your response.1. In the past 14 days have you traveled outside North America?YesNo2. Have you traveled to a state with a high number of infected people (e.g. Washington, California, New York) or had somebody visit you from one of these states?YesNo3. Have you had close contact with a person known to have COVID-19?YesNo4. Have you had a fever of 100.4 or higher or had a cough or shortness of breath?YesNo5. Have you taken a fever reducing medication in the past 24 hours?YesNoThank you for your cooperation. We’re all in this together. George K. Johnson, O.D.