COVID-19. Screening. | Sunnyvale Dentist

Name *

First

Last

Email - if you would like to send yourself a copy of this screening form.

Email

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Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *

Yes
No

Are you/they having shortness of breath or other difficulties breathing? *

Yes
No

Do you/they have a cough? *

Yes
No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes
No

Have you/they experienced recent loss fo taste or smell? *

Yes
No

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

Yes
No

Is your/their age over 60? *

Yes
No

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *

Yes
No

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