Rockbridge Area Hospice

Covid 19 Risk Assessment

Patient Name
Date of Visit

Please call you patient, and/or their family and ask the Covid Risk Assessment questions found below. These questions must be asked EACH time before you go out and visit your patient. 

Have you or any members of the household had any type of international travel in the last 14 days?
Have you or any members of the household had any type of domestic travel in the last 14 days?
Have you or anyone in the household had contact with anyone with confirmed Covid-19 in the last 14 days?
Have you or anyone in the household had a fever greater than 100 degrees Fahrenheit in the last 14 days?
Have you or anyone in the household experienced new symptoms of difficulty breathing or cough in the last 14 days? (not related to chronic symptoms of seasonal allergies or COPD)

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