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 the office of Elliot Davis, D.D.S. as safe as possible. Thank you for your cooperation and understanding with furnishing this preliminary screening!
1. How do you feel today?
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1
2
3
4
5
Terrible
Excellent
1 is Terrible, 5 is Excellent
2. Have you been tested for COVID-19? If no, please proceed to #2d.
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No
Yes
Not sure
Other
2a. If you were tested, when were you (first) tested?
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Month
-
Day
Year
Date
2b. What was the result?
Result was negative (-)
Result was positive (+)
Tested more than once
Awaiting the result of the test
I am self-quarantining
I tested positive (+) for the antibody test
Other
2c. If you were tested more than once, when was your most recent test?
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Month
-
Day
Year
Date
2d. Do you believe you may have been exposed to COVID-19 in the past 14 days? If "No", skip to Question #3.
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Yes
No
Maybe
Not sure
Other
2e. If you were exposed, when were you most recently exposed?
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Month
-
Day
Year
Date
3. During the past 3 days, please check each symptom which you have had.
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Altered sense of smell
Altered sense of taste
Breathing difficulty
Chills
Cough
Diarrhea
Fever
Headache
Muscle pain
Rash
Shakes
Shortness of breath
Sniffles
Sore throat
None of the above
Other
4. Are you immunocompromised?
*
Yes
No
Maybe
Not sure
Other
5. Have you been in contact with someone who was certified via a test to be COVID-19 Positive (+)?
*
Yes
No
Maybe
Not sure
Other
6. Have you been contacted by a COVID-19 Contact Tracer Representative?
*
Yes
No
Maybe
Not sure
Other
Please provide any additional comments or observations:
Full Name
*
First Name
Last Name
Please verify that you are human
*
E-mail
*
Mobile Phone Number
*
-
Area Code
Phone Number
Submit
Should be Empty: