MDS Online Screening Questionnaire

MDS Online Screening Questionnaire

Please answer the following questions with HONESTY.
Patient's Name*

First NameMiddle NameLast Name
Facebook name of person booking:
Age
Gender
Occupation
Are you our returning patient?*

YESNO
Address*

Home No. / Street Address

Barangay

CityState / Province

Postal / Zip Code
Contact Number*
Dental concern:*
1. Are you vaccinated?*

YesNo
2. Have you or any member of your household traveled to any part of Panay or Philippines within the last 30 days?*

YesNo
If yes, where?
3. Have you attended a mass gathering, reunion with relatives / friends or parties within the last 30 days?*

YesNo
4. Have you recently obtained a COVID-19 test?*

YesNo
5. Have you been in close contact with a COVID-19 positive patient?*

YesNo
6. Have you been in close contact with a person under investigation (PUI)?*

YesNo
7. Have you been in close contact with a person under monitoring (PUM)?*

YesNo
8. Do you have flu-like/respiratory symptoms? If so, please check from the following:*

fevercoughrunny nosesore throatheadacheshortness of breathchillsbody weaknessdiarrheaNONEOther
9. Is there any medical condition we should be aware of before starting your treatment?*

YesNo
If yes, please Indicate:
10. Are you currently experiencing a DENTAL EMERGENCY? (uncontrolled dental/oral pain, swelling, bleeding, infection, trauma)*

YesNo
Appointment
THIS IS NOT YET YOUR BOOKING CONFIRMATION.

Please wait for our approval.

Thank you for your cooperation.

- MDS Management
Should be Empty: