Covid-19 Screening Form
Please complete ALL fields, and return at least 3 days prior to your appointment
Patient's name: -
*
First Name
Last Name
Email
*
example@example.com
Mobile Number
*
Date of Birth
*
/
Day
/
Month
Year
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Have you had a high temperature (37.7C) during last 2 weeks?
*
Yes
No
(Feeling hot to touch on chest, back or forehead)
Have you had a new, continuous cough during last 2 weeks
*
Yes
No
(coughing for more than 1h, or more coughing episodes in 24h)
If you usually have a cough, was it worse than normal?
*
Yes
No
Have you had loss or change to your sense of smell or taste during last 2 weeks?
*
Yes
No
(You could not smell or taste anything, or things smell or taste different from normal)
Have you had shortness of breath during last 2 weeks?
*
Yes
No
Have you travelled to any other countries outside the UK during the last month?
*
Yes
No
Did you undergo quarantine after such travelling?
*
Yes
No
Have you been in close contact with someone with confirmed coronavirus?
*
Yes
No
Have you ever been asked to self- isolate during the lockdown?
*
Yes
No
Are you a vulnerable patient?
*
Yes
No
(Click here to view 'who is a vulnerable patient)
Are you an extremely vulnerable patient- shielded?
*
Yes
No
(Click here to view 'who is shielded)
Have you followed social distancing of 2m guidelines at all times?
*
Yes
No
Do you have pain/problem?
*
Yes
No
Or, is it just a routine non- essential appointment that you would like to book?
*
Yes
No
Did you contact the dentist on emergency line during the lockdown?
*
Yes
No
Have you had any changes in your medical history since your last visit?
*
Yes
No
Are you currently suffering from hay fever and/or sneezing ?
*
Yes
No
Please provide more detail regarding each of the 'Yes' answers :
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Signature
*
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Date
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Day
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