COVID-19 Safety Screening Checklist. COVID-19 is a novel coronavirus which has been declared a worldwide pandemic by the World Health Organization. Precautions are being taken to make our office as safe as possible. Thank you for your cooperation and understanding with furnishing this preliminary screening!

COVID-19 Safety Screening Checklist

COVID-19 is a novel coronavirus which has been declared a worldwide pandemic by the World Health Organization. Precautions are being taken to make our office as safe as possible. Thank you for your cooperation and understanding with furnishing this preliminary screening!
Full Name *

First Name Last Name
Email
example@example.com
Phone Number *

Area Code Phone Number
1. Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *

Yes No
2. Are you/they having shortness of breath or other difficulties breathing? *

Yes No
3. Do you/they have a cough? *

Yes No
4. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes No
5. Have you/they experienced recent loss of taste or smell? *

Yes No
Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. *

Yes No
Is your/their age over 60? *

Yes No
Do you/they have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders? *

Yes No
Have you/they traveled in the past 14 days? *

Yes No
Have you been tested for Covid-19? *

Yes No
If yes. When? *

Month Day Year
Signature

Clear
Should be Empty: