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North Shore Dental Group COVID-19 Screening
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3
Questions
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HIPAA
Compliance
1
Name
*
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First Name
Last Name
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2
Email
example@example.com
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3
Please base your answers on the last 14 days
*
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Please make sure to answer each question.
Yes
NO
Do you have a fever or have you felt hot or feverish?
Row 0, Column 0
Row 0, Column 1
Are you having shortness of breath or other difficulties breathing?
Row 1, Column 0
Row 1, Column 1
Do you have a cough?
Row 2, Column 0
Row 2, Column 1
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Row 3, Column 0
Row 3, Column 1
Have you experienced loss of taste or smell?
Row 4, Column 0
Row 4, Column 1
Are you or have you been in contact with any confirmed COVID-19 positive patients?
Row 5, Column 0
Row 5, Column 1
Are you over the age of 60?
Row 6, Column 0
Row 6, Column 1
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Row 7, Column 0
Row 7, Column 1
Have you traveled to any regions affected by COVID-19?
Row 8, Column 0
Row 8, Column 1
Do you have a fever or have you felt hot or feverish?
Are you having shortness of breath or other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you experienced loss of taste or smell?
Are you or have you been in contact with any confirmed COVID-19 positive patients?
Are you over the age of 60?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you traveled to any regions affected by COVID-19?
Yes
Row 0, Column 0
NO
Row 0, Column 1
Yes
Row 1, Column 0
NO
Row 1, Column 1
Yes
Row 2, Column 0
NO
Row 2, Column 1
Yes
Row 3, Column 0
NO
Row 3, Column 1
Yes
Row 4, Column 0
NO
Row 4, Column 1
Yes
Row 5, Column 0
NO
Row 5, Column 1
Yes
Row 6, Column 0
NO
Row 6, Column 1
Yes
Row 7, Column 0
NO
Row 7, Column 1
Yes
Row 8, Column 0
NO
Row 8, Column 1
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