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100 PIPER HILL DR. SUITE D ST. PETERS, MO 63376

(Text us) (3937)

Our Focus is on You!

COVID-19 Screening Questionnaire

Patient Full Name

Patient Date of Birth (mm/dd/yyyy - ex: 02/06/1999)

The health and welfare of our patients and staff is our top priority.

Please complete the COVID-19 screening questionnaire below to confirm your appointment for optometric services at Appelman Eye Associates

Required Screening Questions:

1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Questions

Yes/No/?

Fever or Chills

Difficulty breathing or shortness of breath

Cough

Sore throat/trouble swallowing

Runny nose/stuffy nose or nasal congestion

Decrease or loss of smell or taste

Nausea, vomiting, diarrhea, abdominal pain

Not feeling well, extreme tiredness, sore muscles

2. Have you traveled outside of the country in the past 14 days?

3. Have you had close contact with a confirmed or probable case of COVID-19?

If you answered yes to any of the questions 1-3, please reschedule your appointment and contact your health care provider.

Signature of patient / legal guardian (type your name)

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Appelman Eye Associate's Eye Doctors and Staff Provide
Quality Eye Care and Personalized Service You Can Trust

OFFICE HOURS:
MON	9:00 - 5:00
TUE	9:00 - 7:00
WED	9:00 - 5:00
THU	9:00 - 7:00
FRI	9:00 - 5:00
SAT	Closed
SUN	Closed

Ready for the next step?

REQUEST YOUR EYE HEALTH
AND VISION EXAMINATION

Appelman Eye Associates is located in St. Peters Missouri
Dr. Appelman, Dr. Carenza, and the caring staff provide personalized 'One-on-One' eye care. We have earned our reputation by providing the finest in eye health care, eyewear, and contact lenses at affordable prices.

We will make every effort to take a complete approach to your eye care. This means that we will take the time to not only understand your eye health and visual needs, but your general health, lifestyle, and dietary habits as well. This is somewhat rare in health care today, but we think you will find it to be a refreshing change.

Seeing 20/20 doesn't necessarily mean your eyes are healthy. Many eye problems can only be detected during a thorough eye exam. Our eye doctors uses the latest innovative diagnostic equipment to detect even the smallest changes in your vision and eye health. We will evaluate your risk factors for diseases of the eye. It's important to know that diseases of the eye can also be an indicator of general health issues.

Schedule your Eye health and Vision appointment today with our experienced eye care providers at our St. Peters Missouri office and give your vision the level of care and attention it deserves.