COVID19 Self Assessment Questionnaire
Best Dentist 4 Kids, Hatboro
Patient Name
First Name
Last Name
Date
Date of Birth
Have you traveled to an area that has a high rate of COVID-19?
Yes
No
Do you have a cough?
Yes
No
Do you have a fever?
Yes
No
Do you have an upper respiratory infection?
Yes
No
Have you been in contact with someone that has suspected, or known they have COVID-19?
Yes
No
Date
-
Month
-
Day
Year
Date Picker Icon
Time
Patient Signature (or Parent/Guardian)
*
Submit
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