"> Patient Screening Form – USmile Dental

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Patient Screening Form

Patient Screening Form

    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