Yeung Smiles ADA COVID-19 Health Form

1

Patient Name* This field is required.

First Name

Last Name

2

E-mail* This field is required.

3

Do you/they have fever or have you/they felt hot or feverish recently(14-21 days)?* This field is required.

YESNO

4

Are you/they having shortness of breath or other difficulties breathing?* This field is required.

YESNO

5

Do you/they have a cough?* This field is required.

YESNO

6

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?* This field is required.

YESNO

7

Have you/they experienced recent loss of taste or smell?* This field is required.

YESNO

8

Are you/they in contact with any confirmed COVID-19 positive patients?* This field is required.Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

YESNO

9

Is your/their age over 60?* This field is required.

YESNO

10

Do you/they have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders?* This field is required.

YESNO

11

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)* This field is required.

YESNO

12

Any Special Requests?

13