Covid-19 Screening Questionnaire

Covid-19 Screening Questionnaire
Covid-19 Pre-appointment Screening Questionnaire Name*

First NameLast Name
Date*

MonthDayYear
Date
Covid-19 Test*

I have NOT BEEN tested for the Covid-19I HAVE BEEN tested for the Covid-19
Covid-19 test results (check all that apply)

I tested NEGATIVE for the Covid-19I tested POSITIVE for the Covid-19 virusI tested POSITIVE for the Covid-19 ANTIBODIES
Date of Covid-19 test

MonthDayYear
Date
Why were you tested for Covid? Please provide details below.*
I am taking precautions and following the CDC recommendations. (check all that apply)*

None. I am not taking any precautionsUse hand sanitizerKeeping social distancingWearing a face mask at every outingWearing glovesWearing eye protection
Are you experiencing any of the following symptoms?*

None, I have not had any flu like symptomsFever, or have felt hot or feverish recentlyCoughDifficulty breathingAny flu like symptoms, such as gastrointestinal upset, HeadacheFatigueAny other flue like symptomsLoss of smell or taste
Have you been in contact with anyone experiencing flu like symptoms?*

YesNo
Have you been in contact with any confirmed with the Covic-19 positive patients?*

YesNo
A MUST READ:

Anyone experiencing flu like symptoms, has been with someone expieriencing flu like symptoms or has been with somone who has tested positive for the Covid-19 virus.

1. Please call your physcian regarding your symptoms

2. Please call the office and reschedule elective dental procedures.

3. Please call the office if you are having a dental emergency
California and USA Travel- have you traveled to any of the following Covid-19 areas in the 14 to 30 days? Please check all that may apply.*

I have not traveled outside of South Lake TahoeTruckeeInclineKings BeachCarson CityRenoSacramentoSan FranciscoBay area and surroundingsAnother state
International Travel- have you traveled to any of the following Covid-19 areas in the 14 to 30 days? Please check all that may apply.*

I have not traveled out side of the USAChinaCanadaMexicoSouth AmericaEuropeRussiaOther country not listed
Cruise Ship - Have you traveled on a cruise ship in the 14 to 30 days?*

YesNO
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: