COVID-19 Safety 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 the office of Elliot Davis, D.D.S. as safe as possible. Thank you for your cooperation and understanding with furnishing this preliminary screening!

2. Have you been tested for COVID-19? If no, please proceed to #2d. *

No Yes Not sure
2a. If you were tested, when were you (first) tested?

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
2c. If you were tested more than once, when was your most recent test?

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 *

Yes No Maybe Not sure
2e. If you were exposed, when were you most recently exposed?

Month Day Year
Date
3. During the past 3 days, please check each symptom which you have had. *

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
4. Are you immunocompromised? *

Yes No Maybe Not sure
5. Have you been in contact with someone who was certified via a test to be COVID-19 Positive (+)? *

Yes No Maybe Not sure
6. Have you been contacted by a COVID-19 Contact Tracer Representative? *

Yes No Maybe Not sure
Please provide any additional comments or observations:
Full Name *

First Name Last Name
Please verify that you are human *
Email *
example@example.com
Mobile Phone Number *

Area Code Phone Number
Should be Empty:

COVID-19 Safety Screening Checklist