COVID-19 Screening Questionnaire
Your Name
*
First Name
Last Name
Patient Name (if different)
First Name
Last Name
Email
*
example@example.com
In the last 14 days, has the patient or any member of the household had any of the following?
Fever (over 99.6 degrees F) or chills
*
Yes
No
Muscle or body aches
*
Yes
No
Sore throat
*
Yes
No
Coughing
*
Yes
No
Shortness of breath or difficulty breathing
*
Yes
No
Persistent pain, pressure or tightness in chest
*
Yes
No
Loss of sense of smell or taste
*
Yes
No
Travel by airplane, cruise ship, or train
*
Yes
No
Has the patient, a family member, or any known close contact had:
A diagnosis of COVID-19 infection, or any other communicable disease
*
Yes
No
A test for COVID-19 infection, but waiting on results
*
Yes
No
Symptoms of COVID-19 but not yet tested
*
Yes
No
If the patient, family member, or close contact has been diagnosed with COVID-19 infection, when did that occur?
-
Month
-
Day
Year
Date
If the answer to any of these questions changes before the appointment, I agree to notify Foley Orthodontics as soon as possible. Also, if the answer is yes to any of the previous questions, I understand I will be asked to reschedule the appointment.
*
Yes, I understand
Submit
Should be Empty: