Lakewood Regional Medical Center
Screening of Medical Students for Coronavirus
Due to the State of Emergency declared in LA County related to the
Coronavirus outbreak, we must screen all persons who enter into the
Hospital.
Please answer the following questions and return this form as soon as
possible.
Have you had one or more of the following symptoms within the last 14
days?
 Fever or chills  YES  NO
 Cough, with or without sputum production  YES  NO
 Shortness of breath or difficulty breathing  YES  NO
 Fatigue  YES  NO
 Muscle or body aches  YES  NO
 Headache  YES  NO
 New loss of taste or smell  YES  NO
 Sore Throat  YES  NO
 Congestion or runny nose  YES  NO
 Nausea or vomiting  YES  NO
 Diarrhea  YES  NO
 Significant loss of appetite  YES  NO
 Close contact with a Coronavirus (COVID-19) patient  YES  NO
 Diagnosis of COVID-19  YES  NO
Printed Name
Signature
Date
Please return this screening form to Tracy Swancutt, Medical Staff Services
Director, via fax to 562-582-1911 or via email to
tracy.swancutt@tenethealth.com.
Last Updated 03/05/2020