Covid-19 Screening Questionnaire DateDo you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*--Please Select--Pre-AppointmentIn-Office Yes No Are you/they having shortness of breath or other difficulties breathing?*--Please Select--Pre-AppointmentIn-Office Yes No Do you/they have a cough?*--Please Select--Pre-AppointmentIn-Office Yes No Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*--Please Select--Pre-AppointmentIn-Office Yes No Have you/they experienced recent loss of taste or smell?*--Please Select--Pre-AppointmentIn-Office 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.Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*--Please Select--Pre-AppointmentIn-Office Yes No Digital SignatureDate Δ
