Skyway Dental Clinic
COVID-19 Pre-screening Form
These questions must be answered honestly and to the best of your ability. An answer of YES will likely result in further discussion with your dentist . Please answer the following questions:
Do you have or have you recently a fever or above normal temperature?
Have you experienced shortness of breathe or had trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell?
Do you have a sore throat?
Have you been in contact with someone who has tested positive for COVID-19?
Have you tested for COVID-19?
Have you been tested for COVID-19 and are awaiting results?
Do you have a weakened or compromised immune system? (i.e. due to chronic or autoimmune disease, lung or breathing problems, cancer treatment)
Have you traveled anywhere outside of the state of Minnesota in the last 14 days?
Explain any YES answers in the box below:
Signature: By typing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge:
Should be Empty: