Please fill out this quick Covid-19 Questionnaire
First Name
Last Name
Title
Hygienist
Assistant
Receptionist
Dentist
Email
Do you have a fever, or have you felt feverish recently?
Yes
No
Do you have a cough?
Yes
No
Are you having shortness of breath or any difficulty breathing?
Yes
No
Do you have chills or repeated shaking with chills?
Yes
No
Do you have any muscle pain?
Yes
No
Do you have any recent onset of headache or sore throat?
Yes
No
Do you have any other flu-like symptoms?
Yes
No
Do you have any recent loss of taste or smell?
Yes
No
Have you experienced any recent GI upset or diarrhea?
Yes
No
Are you in contact with anyone who has been confirmed to be COVID-19 positive?
Yes
No
Have you been tested for COVID-19?
Yes
No
If yes, what was the result?
Positive
Negative
Have you been diagnosed with COVID-19?
Yes
No
If yes, when?
Are you over the age of 65?
Yes
No
Do you have any of the following pre-existing conditions
Heart disease, Lung disease, Kidney disease, Diabetes, Autoimmune disorders
Yes
No
