Do you have fever or have you felt hot or feverish in the last 21 days?
YesNo

Are you having shortness of breath or other difficulties breathing?
YesNo

Do you have a cough?
YesNo

Do you have any other flu-like symptoms, such as stomach upset, headaches, body aches or fatigue?
YesNo

Have you experienced a recent loss of smell or taste?
YesNo

Are you in contact with anyone who shows any sign of flu?
YesNo

Are you in contact with anyone who is COVID-19 positive?
YesNo

Have you ever been tested positive for COVID-19 in the last 21 days?
YesNo

Have you been travelling in the last 14 days?
YesNo

I confirm to the best of my knowledge, that the above information is complete and correct. I agree that the information provided above can be used confidentially for medical and internal purposes by U Smile Dental Practice

I have read, understood and agree to the privacy notice

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