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Comfort Dental at Glen Cove COVID-19 Screening
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3
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1
Patient's 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?
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?
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
NO
Yes
NO
Yes
NO
Yes
NO
Yes
NO
Yes
NO
Yes
NO
Yes
NO
Yes
NO
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