Needham Dental | Covid-19 Questionnaire

Full Name *

Date of Service *

Do you have fever above 100.4 F *

Yes

No

Are you experiencing any of the following symptoms

A cough *

Yes

No

Shortness of breath *

Yes

No

Loss of taste of smell *

Yes

No

Any flu like symptoms such as upset stomach, headache, fatigue or pains *

Yes

No

Have you been in contact with someone who has tested positive for Covid-19 in the last 14 days *

Yes

No

If yes, what was the date. Cannot be seen till 14 days after that date.

Have you been tested for Covid-19 in last 14 days *

Yes

No

What is the result of the testing *

+Ve : You must come back 14 days after free of symptoms.

-Ve

Waiting : You must come back after results are back

Have you travelled anywhere during the last 14 days? *

Yes

No

You have to be in quarantine for 14 days before you can come before coming for appointment

Are you over 60? *

Yes

No

Do you have any heart disease, lung disease, kidney disease, diabetes or any other auto immune disease? *

Yes

No

Please List