COVID-19 Screening Form
Rachel Brinker, DMD
Patient Name
*
First
Last
Primary Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Please answer the following:
*
Rows
YES
NO
Do you have a fever or above normal temperature?
Have you experienced shortness of breathe or had trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell?
Do you have a sore throat?
Have you been in contact with someone who has tested positive for COVID-19?
Have you been tested for COVID-19 and are awaiting results?
Have you traveled outside the United States by air or cruise ship in the past 14 days?
Have you traveled within the United States, by air, bus or train within the past 14 days?
Do you have a weakened immune system?
Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy?
Do you take steroids for any conditions? Examples of common steroids are Cortisone, Prednisone, Methylprednisone. Contact your physician or our office if not sure. Also, answer YES if unsure.
Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, or psoriasis?
Do you have diabetes?
If so, do you have to take insulin injections?
Do you have asthma or COPD?
Explain any YES answers in the box below:
Have you tested positive for COVID-19?
YES
NO
If YES, When?
Have you been COVID-19 vaccinated?
YES
NO
If YES, When?
Signature: By signing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge:
*
Use your mouse to sign by holding down the button continuously with your index finger and signing/moving the mouse in the signature box. When finished press “Submit Survey”
Submit Survey to Dr. Brinker
Should be Empty: